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COLUMBIA    UNIVERSITV 
EDWARD  G.  JANEWAY 
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FRONTISPIECE. 
Surface  Topo}:raph\-  During  Moderate  Expiration. 


THE      SIGNS      OF 
INTERNAL    DISEASE 


With  a  Brief  Consideration  of 
the  Principal  Symptoms  thereof 


liY 


Pearce  Kintzing,  B.  Sc,  M.  D. 

Professor  of  Physical  Diagnosis  and  Diseases  of 
the  Heart,  Maryland  Medical  College;  Physician 
to  the  Franklin  Square    Hospital,  Baltimore,  Md. 


ILLUSTRATED 


CLEVELAND  PRESS 

CHICAGO 

1906 


COPYRIGHT,  U)06, 

\i\  THE 

CLEVELAND  PRESS 


Hict^arb  Armstrong,  A.  21T.,  211.  T>. 

In  remembrance  of  kindly  help  and  sympathy 

during  my  earliest  efforts  to  acquire 

the  science  of  medicine, 

and  as  a  tribute  to  his  fifty-four  fruitful  years  of  practice, 

this  book   is  respectfully  dedicated. 


PREFACE. 

This  volume  is  the  ovitgrowth  of  my  lecture  notes.  First  m- 
tended  for  the  students  of  my  classes  at  the  college  and  hospital,  it  has 
grown  gradually  to  its  present  proportions,  when  it  seemed  worthy  of 
wider  circulation. 

While  little  that  is  new  or  original  can  be  said  upon  certain  of 
the  subjects  which  have  been  so  well  worked  over  by  Da  Costa,  Loomis 
and  Gairdner,  who  stand  in  their  relation  to  physical  diagnosis  in  the 
position  occupied  by  the  old  masters  in  the  field  of  art,  yet  the  value 
of  putting  one's  ideas  and  knowledge  of  a  subject  into  concrete  form 
for  teaching  so  far  surpasses  the  endeavor  to  teach  from  the  abstract, 
that  I  offer  no  other  excuse  for  being  chargeable  with  the  offense 
implied  in  Cadmon's— "Of  the  making  of  books  there  is  no  end." 

Most  books  upon  technical  subjects  are  written  by  the  men  of  the 
schools  and  the  laboratories,  who,  with  the  endless  resources  at  their 
command,  are  apt  to  give  small  consideration  and  less  preference  to 
methods  better  suited  to  the  class  of  the  general  profession  which 
might  almost  be  called  its  lay-members. 

I  have  strongly  endeavored  to  keep  these  in  mind  and  to  choose 
always  the  simpler  way  when  it  sufficed. 

I  am  much  indebted  to  Miss  Margery  Comegys  for  artistic  work 
and  help  on  the  plates  and  illustrations  and  to  Dr.  F.  W.  Hachtel  for 
assistance  in  proofreading  and  indexing. 

PEARCE  KINTZING. 


TABLE  OF   CONTENTS 


Section  I.     Diseases  of  the  Chest 
Introduction. 
Methods. 

Symptoms  and  Physical  Signs. 
Case  Taking 
History. 

Classification  of  Symptoms. 
Stethoscopes. 
Phonendoscope. 
Section  II.     Medtc.\l  Anatomy. 

Shapes   and  Types  of  Thorax. 
Divisions  of  the  Chest  and  Abdomen. 
Description   of  their  Contents. 
Landmarks. 
Thoracic  Regions. 
Section  III.     Physical  Examin.vtions. 
Inspection. 

Types  of  Respiration. 
Mensuration. 
Palpation. 
Fremitus. 
The  Pulse. 
Thrill. 

Vascular  Phenomena. 
Arterial  and  Venous  Bruits. 
The  Sphygmograph. 
The  Sphj'gmometer. 
Percussion. 
Percussion  Scale. 

Changes  in  Percussion  Produced  by  Disease. 
Auscultation. 
Normal  Respiratory  Sounds. 


jQ  TABLE    l)F    CONTENTS 

Microti  Respiratory  Souiuls. 

Changes  in  Respiratory  Sounds  Produccl  by  D.sease. 
Adventitious  Sounds. 
Auscultation  of  the  Voice  Sounds. 
Crepitation. 
Aids  to  Diagnosis. 
The  Laryngoscope. 
The  Ophthalmoscope. 
Section  IV.    ^mpxoms  ..  PATHn,.oo,c  Go^o■T,o^s  -.  the  Chk.t. 

Cough. 

Expectoration. 

Haemoptysis. 

Dyspnoea.  Classification  of. 

Cyanosis. 

Clubbing  of  Fingers  and  Toes. 

Section  V.     BRONti.rris. 
.\cute. 
Chronic. 
Emphysema. 
Spasmodic   or   Bronchial   Asthma. 

Bronchiectasis. 

Bronchial  Stenosis.  • 

Bronchial  Obstructions. 

Section  VI.     Pleikisy. 

Varieties. 

Dry  Pleurisy. 

Pleurisies  with  I^ffusion. 

Small    Eflfusion. 

Medium   Eflfusion. 

Large  Effusion. 

Diagnosis  from  Pericarditis. 

Pneumothorax. 

Section  Vn.    Lon.xK  Pneumonia. 

Stage  of  Congestion. 
Stage  of  Red  Hepatization. 
Stage  of  Gray  Hepatization. 
Expectoration. 
Bacteriology. 


TABLE    OF    CONTEXTS  11 

Blood  Changes. 
Urine. 

Differential  Diagnosis. 
Broncho- Pneumonia. 
Bacteriolog>'. 

Embolism  of  the  Piilmonarv-  Arter>-. 
Pulmonary  CEdema. 
Section  VIII.     Pulmonary  Tuberclxosis. 
Classification. 
Stages. 

Incipient  Phthisis. 
Consolidation. 
Softening. 
Cavities. 
Cough. 

Expectoration. 
,  Tubercle  Bacilli. 

Haemoptysis. 
Urine  in  Tuberculosis. 
Blood. 
Section  IX.    The  Heart. 

Physiology. 

Anatomy. 

Methods  of  Examining. 

Changes  in  Position. 

Inspection. 

Palpation. 

Percussion. 

Percussion  Areas. 

Changes  in  Areas  Produced  by  Disease. 

.■\uscultation. 

Sounds  of  the  Heart. 

Physiology-. 

Position  of  the  Valves. 

Isolation  of  the  Sounds. 

Alteration  of  the  Sounds. 

Conditions  Affecting  Intensity'  of  Sounds. 

Adventitious  Sounds. 


12  T<VBI^    OP    CONTENTS 

Causes. 

Results  of  Valvular  Impairment. 
Time  of  Murmurs. 
Location  and  .-Kreas. 
Mitral  Murmurs. 
Tricuspid  Murmurs. 
Aortic  Murmurs. 
Pulmonary   Murmurs. 
False  Murmurs. 

Diagnosis  from  Organic  Murmurs. 
Section  X.    Diseases  of  the  Heart. 
Pericarditis 

Pericarditis  with -Effusion. 
Diagnosis  from  Dilatation. 
Chronic  Pericarditis. 
Adherent   Pericardium. 
Hydropcricardium. 
Pneumopericardium. 
Organic  Valvular  Diseases. 
Signs  and  Symptoms. 
Mitral  Insufficiency. 
Stenosis. 

Insufficiency  and  Stenosis. 
Aortic  Incompetency. 
Associated  Murmurs. 
Stenosis. 

Aortic  Stenosis  and  Incompeteni.y. 
Tricuspid  Regurgitation. 
Stenosis. 

Pulmonary  Valve  Lesions. 
Insufficiency. 
Stenosis. 
Order  of  Frequency  of  Simple  and  Combined  Cardiac 

Lesions. 
Congenital  Cardiac  Lesions  and  Diseases. 
Myocardium. 

Hypertrophy  and  Dilatation. 
Myositis. 


T-\BLE    OP    CONTENTS  13 


Aneurysm  of  the  Heart. 
Acute  Endocarditis. 
Section  XL    Thoracic  Aneurysm. 
Special  Signs. 
Pressure  Symptoms. 
Pulse. 
Section  XII.     Examtn.\tion  of  the  Blood. 
Classification  of  Cells. 
Leucocytes. 
Blood  Counting. 
Red  Cells. 
White  Cells; 
Hsematocrit. 

Dried  and  Stained  Films. 
D.ves. 

Malarial   Organisms. 
Haemoglobin. 
Estimation  of. 
Blood  Changes  in  Disease. 
Anaemias. 
Leukaemias. 
Other  Diseases. 
Section  XIII.     Diseases  of  the  Abdomen. 
Introduction. 
Anatomy. 

Regions  and  Contents. 
Methods  of  Examining. 
Diseases  of  the  Peritoneum. 
The  Stomach. 
Cancer  of  the  Stomach. 
Diseases  of  the  Intestines. 
The  Small  Intestine. 
Examination. 
Ulcer  of  the  Duodenum. 
Acute  and  Chronic  Catarrh. 
Colitis. 

Intestinal  Obstruction. 
Physical   Signs. 


14  TABLE    OF    CONTKNTS 

Gall  Stone  Disease. 
Appendicitis. 
Physical  Signs. 
Differential  Diagnosis. 
The  Large   Intestine. 
Dysentery. 
Cancer. 
The  Liver. 
Changes  in  its  Size. 
Diseases  of  the  Liver. 
Spleen. 
Kidney. 
Bladder. 
Uterus. 

Placental    Bruit. 
Foetal  Heart  Sounds. 
Ovarian  Tumors. 
Dropsy. 

Diseases  of  the  Omentum. 
Ascites. 

Forms  and  Diagnosis. 
Secticn  XIV     Examination  of  the  Stomach  Contents. 
Gastric  Juice. 
Composition. 
Methods. 
Test  Meals. 
Acidity. 

Free  Acids. 

Organic   Acids. 

Digestion   Products. 

Starch. 

Pepsin. 

Rennin. 

Motor  Function. 

Residue. 

Macroscopic  Examination  of. 

Microscopic  Examination  of. 


T.VBLE    OP    CONTENTS  15 


Section  XV.     Examination  of  the  Urine. 
Normal  Urine. 
Composition. 
Changes  on  Standing. 
Color. 
Odor. 
Reaction. 
Specific  Gravity. 
Solids. 
Urea. 
Uric  Acid. 
Ethereal    Snlphates. 
Inorganic  Constituents. 
Chlorides. 
Phosphates. 

Abnormal  Constituents. 
Albumin. 
Tests. 
Pus. 
Tests. 

Carbohydrates. 
Qualitative  Tests. 
Quantitative  Tests. 
Bile. 

Diazo  Reaction. 
Diaceturia. 
Urinary  Sediment. 
Chemic. 
Histologic. 
Casts. 
Bacteria. 
Section  XVI.     Examination  of  the  FjECe.s. 
Constipation. 
Fetor. 
Physiology. 
Quantity. 
Consistency. 
Reaction. 


16  TABI,E    OF    CONTENTS 

Composition. 
Meconium. 
Diarrheal  Stools. 
.\cliolia. 

Typhoid  Stools. 
Dysentery. 
Gall   Stones. 
Detection   of. 
Enteroliths. 
Pus. 

Microscopic  Examination. 
Section  XVII.     Tjie  Roentgen   R.\y  in  Diacncsis 
The  Thorax. 
The  Abdomen. 


SECTION  1.  • 

DISEASES  OH  THE  CHEST. 

IXTRODUCTIOX. 

]  t  is  in  diseases  of  the  chest  that  physical  research  has  reached  its 
liighest  development  and  has  been  most  prolific  of  results.  It  may 
be  claimed  that  the  science  of  physical  diagnosis  cannot  be  learned 
from  books.  For  reply,  we  ask, — what  science  can?  Nevertheless, 
the  orderly  setting  forth  of  the  groundwork,  and  a  clear  description 
of  the  phenomena  on  which  are  based  the  inferences  and  conclusions 
of  physical  diagnosis  are  as  necessary  and  helpful  to  the  students  as 
is  the  same  work  in  any  other  department  of  science. 

Yet,  withal,  that  the  ability  to  make  correct  application  of  these 
principles  and  more  especially  the  acquisition  of  capacity  to  interpret 
their  import  and  significance,  must  be  gained  by  bedside  practice,  is 
freely  admitted. 

The  manner  of  investigating  disease  of  the  chest  should  be  taken 
by  the  student  as  a  type  of  the  methods  used  to  investigate  disease 
in  other  parts  of  the  body.  It  is  absolutely  necessarj-  for  the  student 
first  to  make  himself  thoroughly  familiar  with  the  normal  sounds  and 
normal  properties  connected  with  the  functions  of  the  thoracic  organs,  - 
and  to  fix  firmly  in  mind  their  exact  location  and  natural  anatomical 
outlines.  Experience  has  taught  me  that  these  deficiencies  are  the 
great  stumbling  blocks  of  the  student.  This  knowledge  can  be  ac- 
quired by  painstaking  study  upon  the  living  subject,  combined  with 
the  practise  of  the  same  methods  upon  the  healthy  individual  that 
would  be  used  were  he  diseased,  until  these  normal  properties  are  a 
part  of  our  consciousness,  and  departures  therefrom  as  quickly  recog- 
nized as  is  a  false  note  by  the  maestro. 

It  must  be  remembered  that  departures  from  normal  sounds  and 
changes  in  normal  areas  are  caused  by  alterations  in  the  physical 
properties  of  the  organs  or  parts  affected,  and  in  no  other  way.  As 
often  as  we  strike  the  key  of  an  organ  we  elicit  a  certain  invariable 
note,  and  it  is  only  by  altering  the  physical  conditions  or  the  mechan- 


IS  DISEASES    i)V    THE    CHEST 

ism  at  sumo  poiul  bctwccii  kuy  and  pipe  that  we  can  chansjie  the  char- 
acter of  the  sound.  So  the  principal  thoracic  organs,  in  the  accom- 
plishment of  their  functions,  produce  certain  fixed  sounds  which  are 
altered  only  by  changes  in  their  physical  properties  ov  in  the  mechan- 
ism of  the  sound  production.  To  determine  the  extent  and  significance- 
of  these  alterations  is  a  part  of  the  office  of  the  diagnostician.- 

Further  than  this,  all  matter  is  endowed  with  certain  individual 
properties,  and  to  make  manifest  the  different  degrees  in  which  vari- 
ous organs  may  possess  one  or  another  of  these,  is  also  a  part  of  physical 
diagnosis.  Thus,  the  capability  of  producing  resonance,  of  transmit- 
ting or  conducting  sound,  of  vibrating  when  struck,  varies  materially 
with  the  different  tissues  of  the  body,  and  all  of  these  propei'ties  are 
profoundly  affected  by  disease,  by  alterations  in  their  structure,  or 
by  changes  in  their  surroundings.  Yet  disease  must,  indeed,  be  exten- 
sive ere  a  structure  loses  entirely  its  normal  properties.  It  is  manifest 
that  as  long  as  any  of  the  normal  structure  remains  unaltered,  that 
far  will  it  retain  its  normal  properties.  On  the  other  hand,  these  will 
be  appreciably  or  materially  altered  in  some  cases  by  even  slight  dis- 
ease; hence  diagnosis  becomes,  broadly  speaking,  a  question  of  esti- 
mating differences  or  departures  from  the  normal.  Ju.st  as  the  ear  of 
the  better  trained  musician  is  able  to  recognize  even  the  finest  shading 
of  a  note,  so  the  person  more  skilled  in  recognizing  minute  differences, 
in  the  physical  signs  which  it  is  possible  to  elicit  fi'om  the  human  body 
will  be,  other  things  being  equal,  the  better  diagnostician.  But  the 
work  does  not  stop  here.  It  is  the  ability  to  correlate,  to  judge  the 
relative  impoi-tance  of  the  facts  brought  to  light,  and  to  draw  rational 
inferences  therefrom,  which  marks  the  true  diagnostician. 

These  refinements  can  be  learned  only  by  practice  and  perse- 
verance. No  description  suffices.  Only  by  comparisons,  by  compre- 
hensive knowledge  drawn  from  wide  sources,  can  anything  resembling 
perfection  be  reached. 

Gairdner  truly  says,  "The  popular,  and  to  a  certain  extent  the 
half-educated,  medical  mind  is  always  looking  for  a  pathognomonie 
sign,  or  a  broad,  striking,  easy  generalization  from  a  few  facts; 
whereas  it  is  only  by  ripened  experience  that  we  come  to  know  grad- 
ually the  real  value  of  common  and  obvious,  still  more  of  uncommon- 
and  not  obvious,  facts  when  seen  in  combination,  so  as  to  form  con- 
jointly a  basis  for  large  inferences." 


DISEASES    OP    THE    CHEST  19 

METHODS. 

To  the  end  that  we  may  attain  the  objective  point  as  above  set 
down,  it  is  of  the  highest  importance  that  we  proceed  along  orderly 
lines.  The  various  steps  of  the  examintion  bear  a  certain  relation  to 
each  other,  as  to  sequence,  and  this  law  of  harmony  should  not  be 
violated  heedlessly.  Again,  I  emphasize  the  dictum  that  it  is  only 
by  minute,  painstaking  repetitions,  by  careful  comparisons  of  sus- 
pected with  healthy  structures,  that  we  may  hope  to  arrive  at  reason- 
able certainty.  A  hasty  conclusion,  jumped  at  in  one  step  of  the 
examination,  iinconsciously  may  pervert  the  judgment  as  to  other 
palpable  signs,  that  these  may  bear  out  the  false  conclusion.  It  is 
generally  agreed  among  workers  in  this  field  that  the  most  orderly 
progression  is  the  one  here  to  be  followed. 

First,  a  clear,  succinct  history  of  the  case  should  be  obtained, 
keeping  before  the  mind  the  leading  factors  of  what  constitutes  useful 
and  necessary  information,  never  approaching  the  case  with  a  precon- 
ceived idea  of  what  ought  to  be  found.  Nothing,  perhaps,  better  illus- 
trates the  comparative  tact  and  talent  of  different  examiners  than 
their  ability  or  inability  to  obtain  leading  facts.  Much  care  is  neces- 
sary not  to  suggest  the  answer.  It  is  well  established  that  the  com- 
plaisance of  a  large  class  of  patients  prompts  them  to  give  the  answer 
which  they  believe  is  expected.  This  is  especially  true  of  hospital 
and  dispensary  habitues.  Too  much  cannot  be  said  of  the  present 
and  future  value  of  correct  case  records.  That  doctor's  life  must 
indeed  be  busy,  who  has  not  the  time  to  devote  to  this  work.  In 
examining  cases,  a  physician  is  necessarily  guided  by  the  circum- 
stances in  which  he  finds  the  patient,  as  well  as  by  his  knowledge 
and  experience  of  the  condition  with  which  he  is  called  upon  to  deal ; 
hence,  no  single  method  is  applicable  to  all  cases.  We  begin  our 
inquirj^  by  ascertaining  what  the  patient  feels  to  be  wrong.  This 
usuallj^  refers  us  to  some  one  organ  or  part,  and  the  local  investigation 
is  followed  by  a  general  survey  of  allied  functions  or  organs,  with 
inquiries  into  the  manner  in  which  the  present  illness  began,  the 
previous  health  and  kindred  questions,  the  family  lii.story,  the  pre- 
vious history  and  the  present  state  of  the  patient. 

It  is  well  to  separate  the  manifestations  of  the  disorder  into  two 
divisions :  subjective,  or  those  of  which  the  patient  is  conscious,  and 
objective,  those  of  which  the  examiner  gains  knowledge  by  his  own 
senses.     The  former  are  classed  as  synivtoms,  and  the  latter  as  signs 


2  '  DISEASES    OF    THE    CHEST 

or  phy.iical  signs,  a  useful  but  often  disregarded  classiticatiou.  Fur- 
ther, it  is  simple  aud  natural  to  combine  to  a  certain  extent  anatomic 
and  physiologic  facts  in  related  organs.  Thus  the  respiratory  and 
circulatory  systems  are  not  only  closely  allied,  but  have  their  seat  in 
the  thorax;  while  the  genito-uriuary  system  aud  the  various  organs 
of  digestion  are  situated  in  the  abdominal  cavity,  and  may  be  con- 
veniently grouped  consecutively. 

We  begin  with  that  system  which,  from  the  general  aspect  of 
the  case,  seen  s  to  be  the  chief  defaulter,  and  give  it  the  fullest  eon- 
.':id?ration.  Thus,  as  suggested  by  Sir  William  Roberts,  "If  we  find 
orthopncra,  general  anasarca,  and  distended  jugular  veins,  we  begin 
wiJi  tlii^  circulatory  system.  If  we  tind  purulent  expectoration,  ema- 
oiatiou,  and  clubbed  finger-ends,  we  begin  with  the  respiratory  sys- 
tem. If  we  find  albuminous  urine  and  pale,  puffy  countenance,  we 
begin  w-ith  the  urinary  system,"  etc. 

Pew  writers  ou  medical  diagnosis,  and  fewer  still  of  the  sys- 
tematic writers  upon  medical  practice,  offer  the  student  any  sub- 
stantial aid  upon  this  important  subject  of  ease  investigation.  Apart 
from  hospital  internes,  the  great  body  of  students  is  left  to  work 
out  its  own  salvation,  and  devise  a  method  as  the  result  of  experience. 
Experience  means  waste.  Hence  we  append  a  short  synopsis,  modified 
to  suit  our  present  purposes,  derived  chiefly  from  the  plans  proposed 
by  Sir  William  Roberts  in  his  work  on  Practice,  and  the  form  pro- 
posed by  Leach,  as  elaborated  by  Fiulayson,  from  which  source  also 
some  of  the  preceding  suggestions  were  obtained. 

Name.  Sex.  Age.  Address.  Occupation.  Date.  Preliminary 
inspection;  general  information:  definite  inquiry  as  to  what  has 
brought  the  patient  to  seek  advice:  (incorporating  the  patient's  ovni 
statements  in  so  far  as  they  are  relevant.) 

Diagnosis. 


Previous  History. 

Present   Condition. 

1.     Social. 

1. 

External. 

2.     Previous  Health. 

2. 

Special  Organs. 

■i.     Present  Illness. 

3. 

Circulatory  System. 

4.     Family  History. 

■4. 

Respiratory  System. 

5. 

Digestive  System. 

fi. 

Genito-Urinary  Sys 
tem. 

DISEASES    OP    THE    CHEST  21 

Under  the  first  division  we  place  the  leading  facts  in  order 
named : 

1.  Social.  Residence — cliniafe — prevalence  of  special  diseases-- 
occupation — exposure  (heat,  cold,  chemical  products,  dust,) — food — 
stimulants — tobacco — drugs.  Mode  of  life — facts  about  marriage — 
children — parents. 

2.  Previous  Kealth.  Nature  and  character  of  previous  illnesses; 
(confined  to  bed — ^hospital — interruption  of  occupation) — Indica- 
tions pointing  to  special  affections — especially  rheumatism — syphilis 
(adult  and  infantile) — cough — htemoptysis — antemia  (pi'obable 
cause) — sexual  disorders — gain  or  loss  of  weight. 

3.  History' of  Present  Attack.  Onset — cause  of  symptoms — 
treatment  if  any. 

4.  Family  History.  Age  and  causes  of  death — special  diseases 
which  have  shown  themselves. 

Under  the  second  division,  PRESENT  CONDITION,  are  noted 
most  of  the  signs  observed  or  ascertained  by  the  examiner,  which  we 
have  classified  as  ob.Jective.  Of  necessity  some  of  these  signs  fall  into 
both  categories,  but  are  classed  here  owing  to  their  greater  signifi- 
cance. These  points,  in  so  far  as  they  have  special  reference  to  our 
own  subject  are  fully  dwelt  upon  under  the  sections  on  Inspection, 
Ausculation,  etc. 

1.  External  Surface.  Posture, — temperature — appearance — 
color  of  skin — expression  (languid,  sallow,  worn,  wasted,  flush, 
anaemic) — nostrils — lips — arcus  senilis — conjunctivae — state  of  nutri- 
tion— senility — presenilty.  Peculiarities  of  development — deformi- 
ties— joints — tumors — swellings.  Skin — oedema  (where) — perspira- 
tion— rough — dry — cicatrices — rashes — discolorations — superficial  ves- 
sels (especially  of  neck,  abdomen  and  extremities).  Hair — nails — - 
finger-tips.     Glandular  enlargements  (where). 

2.  Special  Organs.  Disorders  of  vision — of  hearing — (ear  dis- 
charges)— other  senses — with  special  details  as  they  bear  upon  the 
case. 

3.  Circulatory  System.  Palpation — Cardiac  pain — dyspnoea — 
pulse — location  of  apex  impact — area  of  impact — character — local 
bulging — neck — pulsation.  Other  regions.  Venous  engorgement — pul- 
sations— cyanosis — thrill  (where) — area  of  percussion — dullness.  Re- 
sults of  auscultation  at  four  cardinal  points.  Murmurs.  Blov)d  exam- 
ination. 


22  DISEASES    OF    THE    CHEST 

4.  licspiiatoiy  Syslcm.  Xuniber  and  cliaractiT  iif  respirations 
— dyspnoea  (inspiratory  or  expiratory) — orthopnea — -effect  of  exer- 
tion— pain — eouirh — sputa — voice — larynx — throat.  Results  of  inspec- 
tion, palpation,  percussion,  auscultation  and  mensuration,  with  due 
attention  to  details  mentioned  hereafter  in  the  special  sections,  care- 
fully describing  and  exactly  locating  all  alterations— the  conduction  of 
heart  sounds — the  resistance.    New  sounds. 

5.  Digest  ire  Sijslcm.  Lips — teeth — gums  (red  or  blue  lines)  — 
tongue.  Fauces.  Thirst — appetite — pain  or  discomfort  after  eating 
— flatulency — acidity — hiccough- — vomiting  (character). 

Abdomen — walls — pain — tenderness — colic — ascites — state  of  bow- 
els— character  of  motions — abnormal  constituents  (worms,  blood, 
pus.) — piles. 

Liver — size — feel.    Spleen — size — feel.     Hernia — other  regions. 

6.  Genito-Urinary  Sijsicm.  Frequency  of  micturition — pain — 
difficulty.  Special  examination  of  urine — quantity  in  24  hours — color 
— rea-ctiou — specific  gravit.v — clearness — albumen — sugar — urea — de- 
posits.    Microscopic  examination  and  results. 

Males,  strietui-es — specific  diseases. 

Females,  menstruation- — its  disorders — leucoi-rhtea — pregnancy — 
specific  diseases. 

For  detailed  method.s  imisued  in  tht-  examination  of  the  nervous 
system  the  reader  is  referred  to  special  works  on  that  sub.ject,  in 
which  they  are  usually  fully  exploited.  Such  notes  as  bear  upon  the 
special  case  may  lie  inserted  conveniently  at  the  end  of  the  al)ove 
scheme. 

The  order  in  which  the  steps  of  the  physical  examination  should 
follow  each  other  has  alread.v  been  intimated  in  the  above  plan. 
Definitely  stated  they  are : 

(a)     Inspection: 

vb)     Palpation: 

(c)  Mensuration : 

(d)  Percussion ;  and 

(e)  Auscultation. 

These  complete  the  ca.se  record  and  bring  us  faee-to-face  with  the 
momentous  conclusion  for  which  our  work  has  been  undertaken, — the 
Diagnosis. 

In  all  rases  in  which  a  justifiabh  diagnosis  can  be  reached  it 
should  h(   n  corded,  as  it  engenders  greater  care  on  the  part  of  the 


DISEASES    OF    THE    CHEST 


23 


examiner  and  carries  a  certain  weight  of  responsibility.  Such  a  record 
■does  not  preclude  a  subsequent  revision  of  opinion,  and  certainly  it 
more  definitely  shapes  the  last  step, — the  Treatment. 

The  first  requisite  of  diagnostic   science   is   a   good  stethoscope. 
While  almost  any  instrument  can  be  madi^  lo  answer,  yet  comfort  in 


Fig.    I — Camman's   Stethoscope. 

the  use  of  the  instrument,  as  well  as  satisfaction  and  refinements  in 
the  results  of  its  use,  vary  widely  with  the  choice.  Avoid  cheap,  badly- 
made  instruments,  as  well  as  heavy,  cumbersome  ones.  See  that  the 
ear  tubes  fit  naturally  and  easily  into  the  ears,  and  that  they  perfectly 
close  the  canals.  A  large  ear-bulb  is  more  satisfactory  than  a  small 
one,  especially  for  protracted  use.     A  metal  spring  is  more  satisfac- 


'24  DISEASES    OF    TUE    CHEST 

tory  thau  gum  elastic,  for  retaining  the  instrument  in  position.  A  too 
weak  spring  is  annoying ;  a  too  strong  one  fatiguing.  The  conducting 
pipes  should  be  of  the  same  caliber  throughout ,  and  not  too  small. 
The  abrupt  shoulder  of  the  jointed  stethoscope  is  an  objection.  The 
bell  should  not  be  too  large,  since  a  large  bell  does  not  admit  of  being 
evenly  placed  against  the  tissues,  especially  in  the  intercostal  spaces, 
and  thus  extraneous  sounds  are  admitted,  which,  being  conducted  to 


Fig.  2 — Bowie's  Stethoscope.  Compound  Form. 

the  ear  of  the  aiiscultator,  cause  confusion.     The  soft  rubber  supple- 
mentary bell,  devised  to  coi-rect  this  defect,  is  not  wholly  a  success. 

The  binaural  stethoscope  has  replaced  entirely  the  single  instru- 
ment. That  devised  by  Dr.  H.  K.  Valentine,  of  Brooklyn.*  is  one  of 
the  best  types  with  which  I  am  familiar,  and  possesses  the  requisites 
named.  The  Bowles  instrument  is  very  satisfactory.  The  ear  pieces 
do  not  ditt'er  from  those  in  ordinary  use :  two  pieces  of  rubber  tubing 

*[)escribe(J  m  the  Xm   York  Medical  Record  of  July  l6,   1892. 


DISEASES    OF    THE    CHEST  2& 

attach  them  to  a  hard  rubber  T,  which  is  again  joined  by  rubber 
tubing  to  the  drum.  The  drum  is  a  steel  disc  somewhat  larger  than  a 
silver  dollar  and  about  twice  as  thick.  It  is  pierced  in  the  center  by 
a  small  hole  into  which  fits  the  elbow-.ioint  pipe  which  connects  it  to 
the  T-piece.  The  face  of  the  drum  is  slightly  cupped,  and  over  this 
concave  face  fits  a  thin,  hard  rubber  disc  which  receives  the  sound 


Fig.   3 — The    Bowie's   Stethoscope. 

vibrations.  The  sounds  are  conducted  with  extraordinary  clearness 
and  intensity,  and  its  use  is  especially  commended  to  those  whose  sense 
of  hearing  is  less  acute  than  normal.  The  flat  disc  admits  of  its  being 
slipped  under  the  back  without  disturbing  the  position  of  the  patient^ 
and  thus  may  be  employed  when  his  condition  forbids  the  use  of  the 
common  type,  as  during  or  immediately  after  severe  haemoptysis,  in 
which  a  recent  experience  of  my  own  was  instructive.     With  its  use,. 


^JG 


mSEA^^ES    OF    THE    CUEST 


breath  sounds  may  he  heard  in  areas  where  otherwise  they  are  in- 
-iuidible,  as  in  the  snbseapular  rejiion.  Tlif  (Inini  nuiy  he  removed  and 
llie  ordinary  bell  l)e  snbstitnti-d  wiieri  desired. 


Fig.    4 — PlioiieiKloscopc. 

The  phonendoseope,  of  Baz/i  and  Bianehi.  is  cumbersome,  ex- 
pensive and  possesses  few,  if  any.  advantages  over  the  one  described. 
Tt  is  excellent  for  auscultatory  percussion,  whereby  the  outlines  of  the 
various  organs  may  be  mapped  out  with  irreat  certainty. 


SECTION  II. 

MEDICAL  ANATOMY. 

^  SHAPES  AND  TYPES  OF  THE  CHEST. 

The  shape  of  the  thorax  and  its  general  capacity  as  well  as  its 
■expansile  powers,  are  influenced  by  age,  sex,  oeeupation,  heredity-  and 
•disease.  Heredity  impresses  its  most  striking  as  weU  as  its  strongest 
peculiarities  upon  those  structures  which  earliest  develop  and  earliest 
reach  maturity,  hence  the  bony  skeleton  is  strongly  influenced  thereby. 

At  birth  the  contour  of  the  chest  is  almost  circular  and  the  thorax 
cylindrical,  but  as  development  proceeds  the  expansion  and  growth  of 


'SQ 


Fig.  5 — Thorax  of  Infant.  Sl'.ow'ing  Conical  Shape. 

tlie  livngs  push  out  the  ribs  in  the  lower  lateral  areas,  the  chest  tlat- 
tens  and  at  the  same  time  becomes  conical.  As  depicted  by  ilorris, 
the  axillary  border  of  the  chest  at  the  eighth  month  shows  little  or  no 
vertical  curvature.  The  relative  shapes  of  mesial  transverse  vertical 
:sections  of  the  infant  and  adult  chest  are  illustrated  by  the  accom- 
panying figure. 

In  old  age  the  shape  of  the  chest  by  slow  retrogression  approaches 


28 


ME11ICAI.     ANATOMY 


once  more  tlie  eyliiuli  ii-iil  tyiic.  Ih'ie  aiiaiii  tlic  most  iiuu'ked  chauires 
take  place  in  the  inferior  areas;  the  lower  circumference  showing  con- 
siderable recedeuce  while  the  middle  zone  ehan<res  least.     Atrophy  of 

the  muscles  of  the  shoulder  airdlr  (icctu's  with  aj;e.  and  the  I'esultint; 


Fig.  6 — Vertical   Mesial   Sections  .^dult   Chest  and   Infantile  Chest.     The   lines 
.•\B  and  CD  arc  parallel. 


Stooping  posture  gives  rise  to  a  seeming  contraction  of  the  ui)per  chest 
zone  which  in  reality  is  very  slight. 

Types  of  Thorax. — Defective  development  combined  with  inher- 
ited tendencies  aided  by  malnutrition  and  imperfect  expansion  pro- 
duce the  most  common  of  thj  vicious  types  of  chest.     Such  are  the 


MEDICAL    AXATOilY  29 

rickety  chest  and  the  variations  thereof  known  as  the  " "  pigeon-breast ' ' 
and  the  phthisical  or  paralytic  chest.  In  its  most  modified  degree  the 
rickety  deformity  consists  simply  of  a  flattening  of  the  lateral  areas 
of  the  chest  with  corresponding  decrease  in  the  transverse  diameter. 
This  results  in  a  degree  of  forward  bulging  of  the  chondi-al  area,  which 
is  spoken  of  as  transverse  constriction.  This  and  the  succeeding  forms 
originate  when  the  bones  are  stiU  soft  and  pliable,  and  in  general  are 
associated  with  deficient  expansion,  which  is  not  only  a  cause  but  a 
permanent  result  of  the  condition. 

In  true  rickets  the  chest  is  flattened  laterally  and  its  contour  is 
trapezoidal,  with  the  wide  border  posteriorly.  Just  outside  the  junc- 
tion of  the  ribs  with  the  cartilages  there  is  an  obliqiie  shallow  depres- 
sion extending  downwards  and  outwards,  which  transverse  constriction 
makes  the  sternal  portion  of  the  chest  unduly  prominent.  A  shallow 
groove  or  curve  passing  outward  from,  the  level  of  the  ensifoi-m  car- 
tilage towards  the  axilla  is  kno^vn  as  Harrison's  sulcus,  or  curve.  It 
corresponds  with  the  attachment  of  the  diaphragm  to  the  cartilages 
and  is  more  prominent  and  deeper  during  inspiration.  Posteriorly 
the  spine  shows  vertical  curvature.  The  Uue  of  junction  of  the  ribs 
with  the  costal  cartilages  presents  small,  nodular  enlargements,  gen- 
erally visible,  always  palpable,  which  appear  as  early  as  the  third 
month  and  disappear  about  the  fifth  year.  They  are  fantastically 
called  the  "'rickety  rosary.""  The  bones  are  spongj-  and  increased  in 
size.    Expansion  is  impaired. 

This  deformity  is  not  peculiar  to  rickets.  Other  conditions  which 
interfere  with  free  respiration  produce  the  same  deformity,  particu- 
larly enlarged  tonsils,  as  pointed  out  by  Dupuj-tren  in  1828.  This 
type  of  chest  is  particularly  interesting  owing  to  the  predilection 
which  its  possessor  has  for  respiratory   disease. 

Lar^Tigismus  stridulus  and  other  spasmodic  affections  of  the 
larynx  are  also  of  frequent  occurrence. 

The  pigeon  or  chicken  breast  is  an  exaggerated  type  of  the  above. 
The  antero-lateral  constriction  reaches  such  a  degree  that  the  sternum, 
especially  the  lower  half,  is  pushed  far  forward  and  a  transverse  sec- 
tion of  the  thorax  appears  nearly  triangular.  The  curvature  of  the 
ribs  lies  almost  entirely  at  their  angle,  whence  they  project  nearly 
straight  forward  to  the  sternum.  The  lower  ribs  are  flared  out  by 
the  liver  and  Harrison 's  sulcus  is  weU  marked.  The  lower  and  lateral 
regions  of  the  chest  retract  with  inspiration.     The  causes  which  pro- 


30 


MEniCAI,    ANATOMY 


duce  the  rickety  chest  are  responsible  for  tlie  chicken  breast  and  the 
tendencies  are  the  same. 

llie  Funnel  Breast.  This  name  has  been  bestowed  by  the  Ger- 
mans ("trichter  brust")  upon  cases  which  present  marlced  recession 
of  the  ensiform  cartilage.  The  name  does  not  apply  to  cases  in  which 
the  cartilage  has  been  bent  inward  the  result  of  occupation,  but  to 
those  in  which  i-espiratory  obstruction  has  resulted  in  its  permanent 


Fig.  7 — Types  and  shapes  of  chest.     Acq-.iired    (occupational)    deformity.     The 
interspaces  on  left  side  are  much  wider  than  on  the  right. 

.■etraction  by  the  act  of  bieathini'-.  In  such  eases  the  lower  sternal  re- 
gion and  intercostal  angle  is  distinctl.y  excavated  and  retracts  during 
inspiration.  Enlarged  ton.sils,  whooping  cough  and  many  respiratory 
affections  are  assigned  as  causes. 

The  Barrel  Chest.  This  deformity  is  also  called  the  emphysema- 
tous chest.  It  may  occur  as  early  as  the  tenth  year,  but  is  generally 
seen  only  in  adult  life.  The  chest  becomes  rounded  and  barrel-shaped, 
the  intercostal  spaces  are  widened,  the  neck  is  short  and  the  back 
bowed,  the  shoulders  arj  bent  forward,  the  arms  hang  lax,  giving  a 


MEDICAL,    ANATOMY 


31 


stooping  appearance  to  the  possessor.  The  circumference  as  taken  by 
the  cyrtometer  shows  a  close  approach  to  a  circle.  In  early  life  the 
change  is  often  due  to  asthma,  the  result  of  naso-pharyngeal  disease ;. 
in  later  life  to  emphysema,  the  causes  of  which  are  discussed  there- 
under. 

The  Phthisical  Chest.    While  Hippocrates  recognized  a  form  oP 
chest  as  predisposing  to  this  ailment,  yet  a  disease  so  universal  is  no 


Fig.  8 — A  normal  adult  male   chest   outline.     6th    costal   cartilage. 

respecter  of  types  and  it  can  scarce  be  said  that  the  description  holds- 
good. 

The  form  of  chest  usually  described  as  phthisical  is  the  result  of 
the  disease  rather  than  one  of  its  causes.  Such  a  chest  is  long,  nar- 
row and  flat  with  depressed  sternum.  The  lung  capacity  is  generally 
stated  as  being  below  normal,  but  Benneke  asserts  that  this  is  a  mis- 
taken belief.  The  ribs  slope  downward  abnormallj',  making  an  acute- 
angle  at  the  ensiform  junction.  All  the  fossa  are  deep,  especially  the- 
clavicular  and  suprasternal,  and  the  scapulje  project  wing-like  from 
behind,  hence  the  name — ^the  ' '  alar  chest. ' ' 

DIVISIONS  OF  THE  CHEST  AND  ABDOMEN. 
Diagnosticians  divide  the  chest  and  abdomen  into  regions  by 
imaginary  lines  and  name  the  various  sub-divisions  for  the  most  part 
in  accordance  with  the  underlying  organs.  Such  sub-divisions  are 
necessary  for  convenience  in  describing  and  locating  the  various  or- 
gans as  well  as  the  lesions  to  which  the  parts  are  subject.  Uniformity 
in  this  regard  among  systematic  writers  is  most  conspicuous  by  its. 


32 


iMEDICAI,     ANATOMY 


absence,  these  usually  makintr  their  sub-divisions  in  accordance  with 
fancied  convenience. 

The  diaphragm  separates  the  chest  or  thoracic  cavity  from  the 
abdominal  cavity.  The  diaphragm  is  attached  anteriorly  in  the  cen- 
tral line  to  the  ensiform  cartilage,  to  the  lower  border  and  inner 
surfaces  of  the  cartilages  of  the  six  lower  ribs.  While  posteriorly  its 
■ci'ura  are  continued  down  over  the  bodies  of  the  lumbar  vertebrfe 
the  diaphragm  as  a  partition  extends  only  as  far  as  the  lower  border 
of  the  ribs.  It  forms  a  vaulted  roof  to  the  abdominal  cavity,  arching 
on  either  side  higher  than  in  the  middle  portion  where  the  pericar- 
dium is  attached.     It  rises  on  the  right  side  as  high  as  the  upper  bor- 


Fig.  9 — Emphysematous  chest  of  practically  the  same  circvimference  as   Fig.  8. 
Note  approach  to  circle. 

der  of  the  fifth  rib,  and  on  the  left  as  high  as  the  top  of  the  fifth 
interspace.  Viewed  from  in  front  its  line  presents  two  domes,  with  a 
slight  fall  or  "sag"  in  the  middle. 

MEDICAL  ANATOMY. 
Regions  or  Spaces  of  the  Chest.  While  it  is  presumed  that  the 
student  of  physical  diagnosis  is  thoroughly  familiar  with  both  the 
topographical  and  the  relational  anatomy  of  the  parts  studied,  yet  by 
reason  of  the  aids  to  description  which  such  anatomic  depictions 
furnish  to  the  writer,  as  well  as  for  the  ease  of  comparison  and  refer- 
ence which  they  afford  the  reader,  no  work  on  the  subject  is  complete 
which  omits  them. 


MEDICAL    ANATOMY  33 

The  exterior  of  the  trunk  offers  some  well  recognized  landmarks 
which  serve  as  cardinal  points  both  for  description  and  for  location. 
Such  are  the  clavicles,  the  nipples,  the  umbilicus  and  the  ensiform 
cartilage  in  plain  view  anteriorly;  and  the  median  furrow  or  spinal 
gutter,  the  apex  of  the  vertebra  prominens,  the  spine  of  the  scapula 
and  the  crests  of  the  ilia  behind. 

The  space  above  the  clavicle  is  known  as  the  supraclavicular  fossa. 
The  infraclavicular  space  lies  below  each  clavicle,  and  while  its  upper 
border  is  sharply  defined  by  that  bone  its  lower  border  is  separated 
from  the  adjacent  mammary  region  only  by  an  arbitrary  line.  This: 
space  extends  inward  to  the  sternum,  outward  to  the  shoulder,  being- 
bounded  here  by  a  vertical  line  bisecting  the  clavicle  at  its  outer 
fourth.  Emaciation  throws  the  clavicles  into  strong  relief  and  makes 
both  the  fossa  and  the  space  appear  deeper  and  better  marked.  At 
the  top  of  the  sternum  is  the  suprasternal  notch.  The  mammary  region 
extends  outward  from  the  edge  of  the  sternum  to  the  vertical  line  just 
located,  and  from  the  upper  edge  of  the  third  to  the  upper  margin  of 
the  sixth  rib.  The  nipple  occupies  the  center  of  the  area,  being  either 
in  the  fourth  interspace  or,  as  I  have  more  often  observed  it,  over  the, 
fourth  rib.  The  mammary  line  passes  vertically  through  it  and  bisects; 
the  clavicle  at  its  middle  point.  In  mature  females  the  nipple  is  dis- 
placed through  many  causes  and  even  in  the  male  it  lacks  constancy,, 
hence  the  line  is  better  named  the  midclavicular  line.  A  second  ver- 
tical line  parallel  with  the  mammary  line  and  lying  within  that  line  is 
useful  for  descriptive  purposes,  it  is  called  the  parasternal  line  and 
divides  the  space  between  the  nipple  or  midclavicular  line  and  the 
edge  of  the  sternum  into  equal  parts.  The  inframammary  region  ex- 
tends from  the  sixth  rib  to  the  lower  costal  margin.  The  sternal  re- 
gion is  boiinded  by  that  bone.  It  should  be  noted  that  the  length  of 
the  sternum  is  subject  to  considerable  variation  and  is  relatively 
shorter  in  women  than  in  men.  The  transverse  projection  which  marks 
the  union  of  its  first  and  second  parts  always  can  be  felt  and  corre- 
sponds with  the  cartilage  of  the  second  rib.  The  sternal  region  is. 
divided  into  upper  and  lower  by  the  line  which  separates  the  infra- 
clavicular space  from  the  mammary  region  (third  rib). 

The  axillary  regions  meet  the  mammary  and  inframammary  re- 
gions in  front;  behind  they  are  limited  by  a  vertical  line  dropped 
from  the  posterior  axillary  fold.  The  same  circumferential  line  (sixth 
j-ib)  which  divides  the  mammary  regions  separates  the  superior  axil- 


34  MEDICAI,    ANATOMY 

lary  area  from  the  inlVrior,  which  last  region  extends  downward  to 
the  edge  of  the  ribs.  It  is  convenient  to  divide  these  regions  by  a 
Vertical  line,  the  midaxillary  line,  into  equal  parts,  the  anterior  axil- 
lary region  and  the  posterior  region. 

The  posterior  aspect  of  the  chest  presents  above,  the  scapular 
regions  which  are  anatomically  divided  into  the  supraspinous  fossa 
and  the  infraspinous  fossa-.  The  parts  included  between  the  inner 
edges  of  these  bones  wlim  the  arms  are  pendant  is  the  interscapular 
region.  The  scapula  lie  on  the  ribs  from  the  second  to  the  seventh, 
inclusive.  The  portion  of  the  chest  included  between  the  lower  edge 
of  the  ribs  and  a  line  joining  the  inferior  angles  of  the  scapulae  is 
the  infrascapular  or  subscapular  region.  As  an  aid  to  description  the 
regions  are  bisected  by  a  vertical  line  called  the  midscapular  line, 
which  name  indicates  clearly  its  location. 

Landmarks.  The  top  of  the  sternum  is  on  a  level  with  the  second 
dorsal  vertebra.  There  is  little  or  no  lung  behind  the  first  bone  of 
the  sternum.  The  highest  part  of  the  aortic  arch  lies  one  inch  below 
the  suprasternal  notch.  The  innominate  artery  lies  behind  and  rises 
as  high  as  the  right  sterno-clavicular  joint.  When  either  the  aorta  or 
the  innominate  is  higher  than  normal  its  pulsations  can  he  felt  in 
the  sternal  notch. 

Xo  little  difficulty  may  be  experienced  in  counting  the  ril)s  in  fat 
persons,  hence  it  is  useful  to  know  that : 

1. — The  transverse  projection  on  the  sternum,  above  referred  to, 
corresponds  to  the  center  of  the  eaitilage  of  the  second  rib. 

2." — The  nipple  in  the  male  is  placed  either  over  the  fourth  i-ib, 
or  between  the  fourth  and  the  fifth  ribs  three-fourths  of  an  inch  out- 
side of  their  cartilage. 

3. — When  the  arm  hangs  at  the  side  the  lower  external  border  of 
the  peetoralis  major  corresponds  with  the  position  and  direction  of 
the  fifth  rib. 

4. — A  horizontal  line  drawn  around  the  chest  through  the  nipples 
■cuts  the  sixth  intercostal  space  midway  between  the  sternum  and  the 
spine,  i.  e.,  in  the  midaxillary  line,  which  point  is  often  selected  for 
tapping  pleuritic  effusions. 

5. — When  the  arm  is  raised  the  highest  visible  digitation  of  the 
:serratus  magnus  corresponds  with  the  sixth  rib.  The  digitations  be- 
low correspond  respectively  with  the  seventh  and  eighth  ribs. 


JIEDICAL    AXATOilY  35 

6. — The  lower  angle  of  the  scapula  corresponds  to  the  seventh 
rib.  which  is  the  longest  rib  in  tie  body. 

7. — The  eleventh  and  twelfth  ribs  can  be  felt  even  in  corpulent 
persons. 

(These  seven  points  are  taken  with  modifications  from  Keene's 
surgical  landmarks.) 

The  tips  of  the  spinous  processes  of  the  vertebrfe  may  be  made  to 
show  readily  as  red  dots  by  making  slight  friction  over  their  points. 

THOKACIC  REGIONS  AXD  THEIR  CONTEXTS. 

The  supraclavicular  region  contains  two  structures  of  importance 
to  the  medical  man,  the  apex  of  the  lung  and  the  subclavian  vessels. 
The  apex  projects  above  the  clavicle  behind  the  sterno-eleido-mastoid 
and  between  the  sealenii  muscles  for  a  distance  varying  from 
one-half  an  inch  to  an  inch  and  three-quarters,  (Holden).  In  extreme 
cases  it  projects  above  the  rib  as  much  as  two  inches,  especially  the 
left  apex  which  is  generally  the  higher  of  the  two.  The  artery  crosses 
the  first  rib  at  the  outer  border  of  the  stemo-mastoid  muscle  where  it 
arches  over  the  lung  apex.  By  elevating  the  shoulder  to  relax  the  tis- 
sues the  beating  of  the  artery  can  be  felt  easily  in  the  subclavian 
fossa.  Just  in  front  of  it  empties  the  external  jugular  vein;  behind 
it  the  internal  jugular. 

The  Clavicular  region  lies  behind  the  clavicle.  Owing  to  the  slant 
of  the  ribs  the  inner  third  of  the  clavicle  overlies  the  first  rib,  the  mid- 
dle third  overlies  the  first  and  the  second  ribs.  The  bone  is  so  sepa- 
rated from  the  lung  that  no  typical  lung  note  is  obtainable,  yet  direct 
percussion  upon  the  clavicle,  as  explained  further  on,  often  elicits  the 
first  signs  of  apical  change. 

The  innominate  artery  extends  upwards  as  high  as  the  upper  limit 
of  the  right  sterno-clavicular  joint  where  it  bifurcates  into  the  right 
common  carotid  and  right  subclavian  arteries  (Morris).  The  right 
innominate  vein  lies  immediately  outside  of  the  artery.  The  left 
common  carotid  arterj'  lies  behind  the  left  sterno-clavicular  articula- 
tion and  the  left  innominate  vein  passes  in  front  of  both  innominate 
and  carotid  arteries  as  it  traverses  the  space  behind  the  manubriiun 
to  reach  the  right  vein  behind  the  first  rib.  Between  the  sterno- 
clavicular articulations  lies  the  Suprasteriml  region,  or  Interclavicular 
notch,  whose  lower  border  is  the  top  of  the  sternum.  It  contains  tne 
trachea  in  the  center.     The  vessels  lying  behind  its  joints  have  been 


36 


5IEDICA1,    ANATOMY 


named.  In  case  of  dilatation  of  the  aorta  or  upward  displacement  of 
the  heart,  the  vessel  may  be  elevated  above  the  notch  where  its  pulsa- 
tions can  be  felt  or  even  seen.  In  these  eases  backward  displacement 
of  the  trachea  is  usual. 


r->^--- 


w- 


I.e. 


Fig.   10 — The   normal  Thorax.      (Male  adult.) 
Midclavicular    line.      PA    Parasternal    line. 

Infracostal   line. 


Showing  reference   lines. 
IF    Inframammary    line. 


MC 
IC 


The  infraclavicular  spaces  overlie  the  lung  substance  and  as  no 
other  structures  are  in  contact  with  the  chest  wall  within  their  areas, 
we  get  here  the  typical  lung  sounds.     The  superior  vena  cava  lies 


PLATE  II. 


RELATION  OF  LUNGS  TO  THE  THORAX 

The  lobes  are  outlined  in  red.     The  pleural  reflection  in 
black.     Note  the  continuation  of  pleura  below  lung  border. 


MEDIC^VL    ANATOMY  37 

partly  behind  the  chondro-sternal  junction  on  the  right  side  and  be- 
hind the  tirst  and  second  intercostal  spaces,  reaching  the  right  auricle 
behind  the  third  cartilage  (Morris).  It  is  covered  by  the  edge  of  the 
lung.  The  right  aiiricle  lies  behind  the  third  cartilage  and  in  the 
third  interspace  beyond  the  sternum,  but  is  well  covered  by  the  lappet 
of  the  right  lung. 

The  Mammary  regions  differ  on  the  two  sides.  On  the  right  side 
are  lung,  liver  and  heart.  The  entire  right  surface  area  is  covered  by 
lung.  Beneath  it  lies  the  right  border  of  the  heart  which  projects  be- 
yond the  sternum  more  than  one  inch,  almost  reaching  the  parasternal 
line.  This  border  lies  behind  the  third  and  fourth  ribs  and  their  in- 
terspaces, covered  by  the  edge  of  the  lung  (Luschka).  A  minute 
portion  of  the  right  ventricle  lies  in  the  fifth  interspace  close  to  the 
sternum,  which,  during  forced  expiration  is  uncovered.  The  liver 
rises  beneath  the  dome  of  the  diaphragm  as  high  as  the  fourth  inter- 
space, receding  farther  from  the  chest  wall  as  it  rises. 

On  the  left  side  the  mammary  region  contains  heart  and  lung. 
From  the  left  edge  of  the  sternum  outward  are  the  right  and  left 
ventricles.  The  left  auricular  appendix,  at  the  base  of  the  pulmonary 
artery  is  quite  superficial  in  the  third  interspace.  The  external  boun- 
dary of  the  heart  on  the  left  side  is  a  line  drawn  from  the  point  where 
the  parasternal  line  cuts  the  third  interspace,  to  a  point  slightly  out- 
side the  apex  in  the  fifth  interspace,  the  line  curving  outward  and 
downward  in  its  direction. 

All  of  this  area  is  covered  by  lung  except  the  tongue-shaped  por- 
tion of  the  ventricle  which  is  known  as  the  area  of  absolute  cardiac 
dullness,  a  small  triangle  whose  sides  are  drawn  through  these  three 
points,  (a)  the  apex,  (b)  the  base  of  the  xiphoid,  and  (c)  the  junc- 
tion of  the  fourth  rib  with  the  sternum. 

The  Inframammary  region,  right  side.  The  lower  edge  of  the 
right  lung  follows  closely  the  sixth  rib  as  far  out  as  the  nipple  line, 
thence  it  passes  slightly  downward  and  outward  to  the  seventh  rib. 
The  diaphragm  rises  to  its  highest  point  just  inside  the  right  nipple 
(midclavicular)  line  which  is  as  high  as  the  top  of  the  fifth  rib  (Mor- 
ris), and  separates  the  lung  from  the  liver.  The  liver  in  this  same 
line  extends  downward  to  the  edge  of  the  ribs  where  it  can  be  felt  on 
inspiration.  On  deep  inspiration  its  border  projects  still  lower.  This 
border  may  be  traced  upwards  towards  the  umbilicus  on  an  oblique 
line.    In  front  in  the  middle  line  the  lower  border  of  the  liver  extends 


38  MEDICAI-    ANATOMY 

downward  to  a  point  about  half  way  between  tlie  xiphoid  cartihige 
and  the  navel  (Quain).  ]\Iy  observation  is  that  this  distance  is  too 
great,  probably  one-third  being  more  nearly  accxu-ate  than  one-half, 
but  the  distance  from  the  navel  to  the  xiphoid  varies  greatly.  For 
'(V'omeh  the  measurement  given  by  Quain  is  much  more  nearly  correct. 
Here  the  line  of  liver  border  is  from  the  ninth  right  to  the  eighth 
left  costal  cartilage,  "crossing  the  middle  line  about  a  hand's  breadth 
below  the  sterno-xiphoid  articulation   (Godlee). 

In  order  to  complete  the  description  of  the  liver  it  is  only  neces- 
sary to  add  that  posteriorly  it  is  opposite  the  ninth,  tenth  and  eleventh 
dorsal  vertebrie,  and  that  on  the  right  side  it  extends  between  the 
sdventli  and  eleventh  ribs,  and  in  the  mammary  line  from  the  fifth 
to  the  ninth  costal  cartilage. 

The  Left  Inframammary  region  differs  materially  from  tlir  right. 
The  left  lobe  of  the  liver  extends  aci-oss  the  sternum.  It's  extreme 
left  point  is  about  an  inch  and  a  half  beyond  the  left  margin  of  the 
bone  (Quain).  The  lower  lobe  of  the  left  lung  covers  the  area, 
reaching  from  the  fifth  to  the  seventh  costal  cartilage,  then  passing 
outwai'd  and  downward.  The  cardiac  half  of  the  stomach  rises  un- 
der the  left  dome  of  the  diaphragm  to  the  top  of  the  fifth  rib  and  ex- 
tends outward  as  far  as  the  anterior  axillary  line.  The  degree  of  dis- 
tention and  the  nature  of  the  stomach  contents  influence  materially  its 
position. 

The  Sternal  region  is  divided  into  upper  and  lower  areas.  In  in- 
spiration the  top  of  the  sternum  corresponds  to  the  fibro-cartilage  be- 
tween the  second  and  third  thoracic  vertebrte  and  is  distant  about  two 
and  a  half  inches  from  the  spine  (Holden).  There  is  little  or  no  lung 
behind  the  first  bone  of  the  sternum.  The  trachea  continues  down- 
ward in  the  central  line  and  bifurcates  behind  the  joint  formed  by 
the  manubrium  and  the  gladiolus.  Lying  on  this  bifurcation  is  the 
aorta,  reaching  within  one  inch  of  the  sternal  notch.  Behind  the 
trachea  is  the  oesophagus.  The  left  innominate  vein  crosses  imme- 
diately behind  the  upper  border  of  the  manubrium  to  reach  the  supe- 
rior cava  on  the  right  side  in  the  first  interspace.  Behind  the  vein 
ascend  the  great  branches  from  the  aorta.  The  lower  sternal  region 
is  the  part  covered  by  the  gladiolus,  or  second  piece  of  the  bone.  Be- 
hind its  upper  area  the  thin  edges  of  the  liings  meet  on  full  inspira- 
tion as  far  down  as  the  fourth  rib  where  the  left  lung  diverges  to 
uncover  the  heart ;  the  right  sometimes  extends  just  beyond  the  mid- 


MEDICAL    ANATOMY 


39 


LfT  K.inNEY 


^ 


RicriUviawt)  J 


Fig.  II — The  Thorax.  Posterior  Reference  Lines.  Scapulse  drawn  outward. 
A  Line  of  division  between  the  lobes  of  the  hmg.  B  Lower  limit  of  lung. 
CC   Interscapular  lines.     D   Suprascapular  line.     E  Infrascapular   line. 


MEDIC.U.    AXATOilT 


41 


die  line  (Holden).  The  bronchi  subdivide  outside  the  edge  of  the 
sternum,  deep  in  the  mediastinum.  The  primary  bronchi  diverge 
opposite  the  second  rib  cartilage.  The  right  is  more  horizontal  than 
the  left  and  slopes  down  to  the  level  of  the  fourth  dorsal  vertebra. 
The  left  is  smaller  than  the  right  but  longer  and  more  inclined,  reach- 
ins  the  level  of  the  fifth  vertebra.     The  beguining  of  the  aorta,  the 


FIRST    MB         

SECOND    RIB 

THIRD  RIS     - 

CLftVlCLl 
SCflPOLA 


-The  relation  of  the  clavicle  to  the   ribs 


inner  portion  of  the  right  auricle  and  the  central  portion  of  the  right 
ventricle  lie  to  the  front  in  this  region.  The  lower  extremity  of  the 
sternum  is  marked  by  the  junction  of  the  ensiform  cartilage.  It 
usually  recedes  from  the  surface  presenting  the  depression  known  as 
the  scrobiculus  cordis,  or  pit  of  the  stomach,  lying  opposite  the  sev- 
enth cartilage. 

Immediately  below  the  sternal  region  between  the  inframammary 
regions  lies  a  portion  of  the  Epigastric  region.  It  is  chiefly  occupied 
by  stomach  and  liver.  The  quadrate  lobe  of  the  liver  lies  immediately 
to  the  right  of  the  umbilical  line,  and  adjoining  it  still  further  to  the 
right  is  the  gall  bladder,  opposite  the  ninth  costal  cartilage,  close  to 


42 


ilEDICAL    ANATOMY 


the  outer  edpe  of  the  rectus  muscle.  When  full  the  bladder  is  pal- 
pable; when  distended  its  position  is  oi'ten  marked  hy  a  spherical  swell- 
ing of  the  parietes. 


SUPRASTERN'RL 

NOTCH 


CLIWICLE. 


INOp^lg 


Fig.  13 — The  diaphragm.    Relation  to  thorax.    The  caval  opening  is  seen  on  the 
left,  the  oesophageal  opening  on  the  right  of  the  ensiform ;  above  it  the  aorta. 

The  Axillary  regions  are  occupied  by  lung  substance  and  are 
alike  on  the  two  sides.  The  lower,  or  infra-axillary,  regions  differ  as 
to  their  contents.    On  the  right  side  in  the  posterior  axillary  line  the 


MEDIC^Ui    ANATOMY 


43 


UPPiR    MAMMARY  LINE. 


fil'M-  MAMMftRY   Lli^E. 


PIAPHRflGM. 


Fig.  14 — The  normal  thorax,  with  reference  lines  and  position  of  diaphragm. 
Lateral  view. 


MEDICAL    ANATOMY  45 

lung  reaches  the  eighth  rib  (Morris).  This  margin  of  the  lung  de- 
scends about  an  inch  and  a  half  on  full  inspiration  (Godlee).  Hence 
the  numerous  discrepancies  met  with  in  description.  The  liver  ex- 
tends below  the  lower  lung  margin  to  the  free  border  of  the  ribs.  On 
the  left  side  the  lung  has  the  same  relations  as  on  the  right.  The 
spleen  lies  a  little  behind  the  mid-axiUary  line,  its  long  axis  corre- 
sponding with  the  tenth  rib,  the  viscus  reaching  from  the  ninth  to  the 
lower  border  of  the  eleventh  rib.  Its  anterior  border  is  marked  by  a 
line  dra^vn  from  the  left  sterno-clavicular  joint  to  the  tip  of  the  elev- 
enth rib.  The  cardiac  end  of  the  dilated  stomach  projects  into  the  left 
infra-axillary  region. 

The  Scapular  regions  do  not  differ  on  the  two  sides.  They  con- 
tain lung  tissue.  The  incisura  of  upper  and  middle  lobes  cuts  the 
fifth  rib  from  above  downward  on  a  long  diagonal. 

The  Interscapular  region  is  chiefly  occupied  by  the  dorsal  ver- 
tebra?, in  front  of  which  is  the  cesophagus.  StiU  more  anteriorly  is 
the  trachea  with  its  subdivisions  as  noted.  The  point  of  tracheal 
division  corresponds  to  the  fourth  or  fifth  thoracic  vertebras  (Morris). 

The  Subscapular  region,  from  the  seventh  rib  to  the  inferior  mar- 
gin of  the  thorax,  for  the  most  part  covers  the  lungs.  Holden  says, 
' '  Opposite  the  angles  of  the  scapulee,  the  arms  being  close  to  the  sides, 
the  lungs  extend  to  the  tenth  ribs. ' ' 

It  should  be  emphasized  that  the  pleural  sac  extends  lower  down 
than  the  lung  all  along  the  lower  margin  of  the  thorax.  Thus,  near 
the  sternum  the  lower  margin  of  the  sac  stretches  along  the  seventh 
rib  cartilage;  in  the  axillary  line  it  reaches  the  lower  margin  of  the 
ninth  rib;  posteriorly  it  reaches  as  low  as  the  twelfth  rib,  which  cor- 
responds to  the  tip  of  the  eleventh  thoracic  spine. 

Holden  caUs  attention  to  the  ease  with  which  tapping  of  the 
pleural  sac  may  be  performed  between  the  eleventh  and  twelfth  ribs, 
"but  not  with  a  trochar,  since  a  trochar  would  penetrate  both  layers 
of  the  pleura  and  go  through  the  diaphragm  into  the  abdominal  cav- 
ity. The  operation  should  be  done  cautiously  by  an  incision  begin- 
ning about  two  inches  from  the  spine,  on  the  outer  border  of  the  erec- 
tor spinas  on  a  level  between  the  spines  of  the  eleventh  and  twelfth 
thoracic  vertebra.  The  intercostal  artery  wiU  not  be  injured  if  the 
opening  be  made  below  the  middle  of  the  space,  which  is  very  wide." 

The  vertical  field  of  the  kidneys  corresponds  to  the  last  thoracic 
and  the  two  upper  lumbar  vertebrae,  the  right  lying  in  most  cases 


46  MEDICAL    ANATOMY 

from  a  third  to  a  half  inch  lower  than  the  left,  but  exceptions  to  this 
rule  are  frequent.  They  extend  inward  far  enouph  to  overlap  the 
tips  of  the  transverse  processes  of  the  vertebra  named. 

The  spleen  slightly  overlaps  the  left  kidney  opposite  the  upper 
half  of  the  kidney's  outer  border.  If  the  hiatus  diaphragmaticus  is 
well  marked  the  kidneys  come  into  relation  with  the  pleura,  the  dia- 
phragm  intervening. 

The  cardiac  orifice  of  the  stomach  lies  to  the  left  of  the  body  of 
the  ninth  dorsal  vertebra  (Holden). 


SECTION  III. 

PHYSICAL  EXAMINATION. 

INSPECTION. 

Inspection  is  the  art  of  observation.  Minute  diiSerences  which 
the  novice  utterly  overlooks  may  be  detected  readilj'  by  the  trained 
eye,  and  valuable  information  gained  thereby.  Indeed,  it  is  often 
possible  merely  by  inspecting-  the  chest  to  make  a  near  approach  to  a 
correct  diagnosis.  By  inspection  we  recognize  changes  in  size,  form 
and  sjinmetry.  In  order  to  give  full  weight  to  inspection  it  is  nec- 
essary that  the  chest  be  uncovered  to  as  great  an  extent  as  may  be 
possible  without  undue  risk  to  the  patient  by  reason  of  exposure,  or 
imduly  wounding  the  modesty  of  young  females.  Place  the  patient 
in  the  best  obtainable  light;  when  the  condition  of  the  patient  admits 
it  is  preferable  that  he  stand  or  sit,  since  the  recumbent  posture  is  not 
so  favorable  for  observation. 

The  first  point  to  be  observed  is  the  type  of  the  chest,  whether 
long  and  narrow,  fiat  and  .shallow,  or  deep.  The  normal  chest  is 
symmetrical  and  the  diameters  well-proportioned.  The  interspaces 
are  equal  and  the  clavicles  none  too  prominent.  Note  especially  the 
antero-posterior  diameter  and  compare  it  with  the  transverse  diam- 
eter; carefuUy  compare  the  two  sides  as  to  symmetry  or  asymmetry, 
giving  especial  attention  to  the  anterior,  upper  surface.  Depression 
here  may  indicate  tuberculous  deposits;  local  bulging  in  this  region 
may  be  indicative  of  aneurysm.  Bulging  in  one  lateral  area  may  be 
caused  by  a  pleural  effusion,  while  retraction  of  some  part  may  have 
resulted  from  previous  disease  of  the  lung  or  pleura.  Note  anteriorly 
the  outlines  of  clavicle,  sternum  and  rib,  giving  attention  to  inequali- 
ties of  the  interspaces  and  the  degree  of  obliquity  of  the  ribs;  note 
whether  the  type  of  respiration  be  costal  or  abdominal;  whether  ex- 
piration is  longer  than  inspiration;  whether  the  intercostal  spaces  are 
equal  and  well-marked ;  whether  the  impact  of  the  apex  of  the  heart 
is  perceptible.  (Displacement  of  the  heart  from  various  causes  is  dis- 
cussed under  diseases  of  that  organ.    Uncovering  of  its  anterior  sur- 


48  PriYSICAl,    EXAMINATION 

face  by  retraction  of  the  upper  lobe  of  the  left  lung;  is  referred  to 
under  Tuberculosis.)  Being  familiar  with  the  movements  of  the 
healthy  chest,  you  will  note  changes  in  the  rhythm,  frequency  and 
force  of  both  heart  and  lung  movement.  All  the  above  observations 
should  be  made  during  quiet,  natural  breathing;  whereupon  the  pa- 
tient should  be  instructed  to  essay  forcible  inspiratiim  and  expiration, 
during  which  the  entire  category  should  be  repeated,  and  careful 
comparison  made  with  the  former  set  of  observations.  During  the 
period  of  forced  inspiration  note  carefully  the  expansion  of  the  tho- 
racic walls,  whether  it  be  a  uniform,  expansile  effort,  or  shows  irregu- 
larities, as  occur  in  phthisis  and  after  pleurisies;  or  whether  it  be  a 
cage-like  rise  and  fall  of  the  entire  chest  structure,  with  little  or  no 
true  expansion,  as  in  emphysema.  On  the  posterior  aspect  of  the 
chest  note  whether  there  are  any  deviations  from  the  straight  line  of 
the  vertebral  spines ;  the  distance  of  the  inner  borders  of  the  scapula 
from  the  spine ;  whether  the  lower  angles  are  on  corresponding  levels 
on  the  two  sides ;  and  whether  both  or  either  of  these  bones  project  un- 
duly from  the  body.  A  valuable  sign  of  pneumonia  in  children  is  the 
lack  of  expansion  just  beneath  the  clavicle  on  the  affected  side. 

Three  types  of  breathing  are  recognized:  abdominal,  superior 
costal,  and  inferior  costal.  In  women,  as  the  heritage  of  the  corset, 
superior  costal  breathing  is  the  usual  type.  In  men,  abdominal.  In 
the  normal  chest  the  expansion  is  equal  on  the  two  sides,  and  all  the 
thoracic  diameters  increase  with  inspiration.  In  disease  the  expan- 
sion may  be  unequal.  If  the  thoracic  walls  become  fixed,  the  expan- 
sion is  chiefly  affected  by  the  descent  of  the  diaphragm.  It  is  to  be 
remembered  that  few  persons  are  perfectly  symmetrical ;  usually  in 
right-handed  persons  the  right  side  is  more  developed  than  the  left, 
while  in  left-handed  persons  the  opposite  obtains.  A  corresponding 
slight  deviation  of  the  spine  is  very  common  and  cannot  be  considered 
as  unnatural.  A  considerable  degree  of  alteration  in  the  form,  move- 
ments and  size  of  the  chest  may  occur  without  serious  embarrassment 
to  the  contained  organs  and  without  interfering  with  their  healthy 
functions.  Few  of  us  have  not  been  struck  by  the  extent  to  which 
the  ravages  of  disease  may  affect  an  organ,  and  yet  it  be  able  to  per- 
form its  allotted  duty. 

Alterations  in  Chest  Walls  Produced  by  Various  Diseases.  By 
inspection  alone  we  may  detect  the  presence  of  various  diseases,  or  con- 
clude that  the  patient  has  been  affected  by  them  at  some  more  or  less 


PHYSICAL    EXAMINATION 


49' 


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PHYSICAL    EXAIIINATION  51 

remote  period.  Thus,  pleurisy  often  leaves  an  indelible  stamp  upon 
its  %ietim.  In  the  pre-effusion  stage,  and  even  when  only  slight  effu- 
sion is  present,  there  is  no  apparent  change  in  the  size  of  the  chest, 
but  the  movements  on  the  affected  side  will  be  somewhat  restricted 
and  those  of  the  sound  side  proportionately  increased.  In  the  lesser 
degrees  it  is  difficult  to  detect  this  change  by  the  unaided  eye.  The 
respirations  are  not  full  and  free  but  terminate  abruptly,  with  a  catch, 
as  it  were,  by  reason  of  the  pain  which  develops  when  a  certain  de- 
gree of  expansion  is  reached.  This  sign  is  not  distinctive  of  pleurisy, 
as  it  is  often  present  in  herpes  zoster  and  intercostal  neuralgias. 

Irregularities  and  contractions  show  the  ravages  of  previous  at- 
tacks of  pleurisy.  Old  sinuses  may  exist.  Flattened  areas,  exaggerated 
interspaces  and  over  prominent  fossae  may  be  the  result  of  tuberculosis. 
A  conical  sweling  in  the  upper  area  may  be  the  first  intimation  of  an 
aneurysm  of  the  aorta. 

Mensuration.  Mensuration,  as  applied  to  diseases  of  the  chest, 
furnishes  certain  data  as  to  shape,  size  and  capacity.  By  its  means 
the  actual  outline  of  the  chest  is  ascertained;  the  relative  measure- 
ment of  the  two  sides,  a  comparison  of  its  various  diameters,  and  the 
amount  of  expansion  are  determined  and  may  be  recorded. 

The  instrument  used  for  determining  the  outUnes  of  the  thorax 
is  the  stethometer  of  Quam,  or  the  cyrtometer.  The  latter  consists  of 
two  thin  flat  strips  of  lead,  each  about  twenty-four  inches  in  length, 
joined  together  at  one  end  by  a  piece  of  rubber  tubing.  The  joint  is 
applied  over  the  spine  of  a  vertebra  at  the  desired  height,  and  the 
flexible  strip  accurately  molded  to  the  chest  walls,  noting  the  points 
where  they  overlap  by  a  scratch  on  the  bands  made  over  the  middle  of 
the  sternum.  The  pieces  are  removed  without  disjointing,  and  a  trac- 
ing made  on  a  large  sheet  of  paper.  The  antero-posterior  diameter  is 
marked  from  the  joint  to  the  line  of  overlapping,  or  may  be  meas- 
ured by  calipers.  The  semi-circumferences,  the  transverse  diameters, 
and  other  measurements  are  made  from  the  tracing.  Deviations  in 
the  two  sides  are  strikingly  brought  out  by  superimposing  the  trac- 
ings, which  maj'  be  done  by  folding  the  paper  and  holding  it  towards 
the  light.  The  semi-circumference  increases  in  eases  of  intra-thoracic 
growths,  or  during  the  accumulation  of  pleuritic  effusion.  It  de- 
creases in  the  course  of  pulmonary  tuberculosis,  in  the  deformity  fol- 
lowing the  removal  of  fluid,  and  from  many  other  causes. 


52  I'llVSlCAL    EXAMINATION 

For  ascertaining  the  relative  expansion  of  the  two  sides,  tapes 
joined  at  the  back  serve  an  excellent  purpose. 

Gain  or  loss  of  flesh  and  muscle  affect  the  chest  measurements, 
a  fact  which  is  to  be  taken  into  account  during  treatment  to  re-estab- 
lish pulmonary  expansion,  and  it  must  not  be  forgotten  that  in  right- 
handed  individuals  the  right  semi-circumference  of  the  thorax  may 
exceed  the  left  by  as  much  as  an  inch. 

For  ascertaining  the  comparative  outlines  of  the  two  anterior 
surfaces  of  the  thorax,  and  for  making  records  of  the  same,  I  have 
used  with  much  satisfaction  thin,  narrow  lead  strips.  The  strip  is 
applied  vertically  so  that  one  end  projects  over  the  clavicle,  and  ex- 
tends downward  to  the  edge  of  the  thorax.  Its  relation  to  the  nipple 
being  noted,  it  is  carefully  molded  over  the  clavicle  and  ribs.  A  trac- 
ing of  each  side  is  then  made.  Differences  imperceptible  to  the  naked 
eye  are  brought  out,  but  what  is  more  important,  future  changes  are 
detected.    The  method  is  especially  valuable  in  incipient  phthisis. 

Palpation.  Palpation  is  an  endeavor  to  obtain  information  of  the 
physical  condition  through  the  medium  of  the  sense  of  touch.  It  con- 
sists of  laying  on  the  hands,  or  in  bringing  the  finger  tips  into  con- 
tact -with  various  regions  of  the  body.  In  localized  diseased  conditions 
the  tips  of  the  fingers  should  be  applied,  as  the  larger  area  of  the 
palmar  surface  is  not  so  suitable  for  differentiating  between  circum- 
scribed localities,  and  is  less  sensitive  than  the  tips.  As  a  means  of 
palpation  between  the  ribs,  the  ulnar  surface  of  the  hand  affords  an 
excellent  means,  owing  to  its  high  sensitiveness  and  the  readiness  with 
which  it  fits  into  the  intercostal  depressions. 

When  the  hands  are  brought  in  contact  with  the  thoracic  wall 
overlying  the  lung,  and  the  patient  made  to  speak,  a  di-stinct  succes- 
sion of  vibrations  is  communicated  to  the  hand.  This  is  known  as 
tactile  fremitus*  The  strength  of  the  vibrations  varies  in  both  health 
and  disease  from  the  faintest  tremulousness  to  strong  well- 
marked,  separated  vibrations.  In  health  the  character  of  the  voice 
materially  influences  their  strength,  the  vibrations  being  better 
marked  in  low-pitched,  deep-voiced  men  than  in  higher  voices; 
stronger  in  men  generally  than  in  women,  and  weakest  in  children. 
The  amount  of  tissue  overlying  the  lungs  influences  this  fremitus, 
and  the  vibrations  are  more  appreciable  in  thin  persons  than  in  fat 


*The  phenomenon  is  indiscriminately  called  by  some  writers  tactile  fremitus. 
And  vocal  fremitus. 


PHYSICAL    EXAMIXATIOX 


53 


ones.  Any  form  of  disease  which  increases  the  density  of  the  pul- 
monary tissue  or  increases  its  conduction  power  augments  the  fremi- 
tus, provided  that  the  bronchi  are  open,  and  that  the  air  column 
from  the  lar\Tix  to  the  pulmonary  tissue  is  uninterrupted.  The  sen- 
sation is  due  to  vibration  communicated  to  the  thoracic  walls,  through 
the  medium  of  the  tissues,  from  the  air  in  the  trachea  set  in  motion 
by  the  act  of  speaking.     Hence,  fremitus  is  increased  in  pneumonia 


Fig.    i6 — Ulnar   palpation. 

and  tubercular  deposits.  On  the  other  hand,  conditions  which  sepa- 
rate the  pulmonary  tissues  from  the  chest  wall,  or  diseases  accom- 
panied by  a  diminution  of  the  normal  pulmonary .  density,  lessen  the 
fremitus,  or  even  obliterate  it.  Thus,  when  a  layer  of  air  or  fluid  in- 
tervenes between  the  periphery  of  the  lung  and  the  parietal  wall,  as 
occurs  in  pleuritic  effusions,  plastic  pleuritic  thickening,  pneumo- 
thorax and  in  solid  tumors  the  fremitus  is  decidedly  lessened  or  is 
totally  absent.  In  health  the  fremitus  is  most  marked  on  the  right 
side  just  below  the  clavicle  where  it  is  stronger  than  in  the  corre- 


54 


PHYSICAL    EXAMINATION 


spending  left  area,  probably  due  to  the  anatomical  fact  that  the  right 
bronchus  is  of  larger  caliber,  is  straighter  and  enters  the  lung  on  a 
somewhat  higher  level  than  its  fellow.  Posteriorly,  in  the  right  supra- 
scapular fossa  the  fremitus  is  greater  than  on  the  opposite  side,  for 
the  same  reason.  From  this  fact  it  may  be  deduced  that  if  the  tactile 
fremitus  is  well-marked  and  equal  on  the  two  sides  in  the  areas  named, 
then  it  is  increased  on  the  left  side,  and  further  evidences  of  disease 
should  be  sought  for  at  the  left  apex.  If  fremitus  is  weakened  but 
equal  on  the  two  sides  it  would  indicate  diminution  on  the  right  side. 


Fig.    1/ — Differential  palpation  of  apices  of  lungs. 

When  the  bronchial  tubes  are  more  or  less  occhxded  by  the  ad- 
herence of  tenacious  secretions  or  by  stenosis,  vibrations  similar  in 
character  to  the  voice  vibrations,  produced  by  the  pa.ssage  of  the  air 
through  the  bronchi,  are  communicated  to  the  hand.  This  is  called 
rhonchial  f7-emitus.  It  is  often  present  in  bronchitis,  and  is  particu- 
larly frequent  in  children  suffering  with  the  disea.se.  The  conditions 
necessary  for  its  production  are  the  same  as  those  which  produce  the 
rales  heard  on  auscultation. 

Fremitus  produced  by  coughing  is  called  tussile.  Advantage  may 
sometimes  be  conveniently  taken  of  crying  spells  in  young  children 
to  determine  the  presence  or  absence  of  crying  and  tussile  fremitus. 

Friction  fremitus  results  when  two  inflamed  surfaces  of  the 
pleura  are  rubbed  together,  and  is  often  present  during  the  dry  stage 
of  pleurisy.  More  rarely  it  is  due  to  pericardial  or  peritoneal  fric- 
tion, which  however  may  sometimes  be  felt. 

Next  in  importance  to  fremitus  as  a  contribution  to  our  knowl- 


PHYSICAL    EXAMINATION  55 

edge  by  palpation  ranks  the  location  of  the  cardiac  apex,  as  indicated 
by  the  position  of  the  impulse.  Even  when  visible  on  inspec- 
tion it  maj'  be  more  accurately  located  by  palpation,  and  a  considera- 
tion of  the  many  diseases  which  affect  its  character  and  location  will 
impress  on  one's  mind  the  extreme  importance  attached  thereto. 
Fowler  says :  ' '  The  position  of  the  cardiac  impulse  is  the  key  to  the 
diagnosis  of  many  affections  of  the  chest." 

Other  information  gained  by  palpation  is  a  recognition  of  the 
degrees  of  resistance  offered  by  various  organs,  and  especially  re- 
sistance due  to  increased  density  of  an  organ.  The  finger-tips  may 
detect  the  presence  of  pulsation  or  vascular  thrill,  as  of  an  aneurysm, 
crepitation  eau.sed  by  air  under  the  skin,  or  crepitus,  such  as  results 
from  a  broken  rib. 

The  relative  length  of  the  expansile  excursion  on  bi-eathing  may 
be  appreciated  by  many  better  by  palpation  than  by  inspection.  Hy- 
perffisthesia  and  tenderness  are  revealed  by  palpation. 

THE  PULSE. 

Much  valuable  information  is  gained  by  a  careful  study  of  the 
pulse,  which  with  many  becomes  such  a  routine  procedure  that  the 
gains  are  minimized.  Intelligent  palpation  of  the  pulse  enables  us  to 
recognize  the  febrile  state,  to  estimate  the  general  strength  of  the 
patient  during  the  course  of  disease,  as  well  as  to  suspect  solely  from 
its  character  the  presence  of  various  conditions  and  complications. 
The  three  chief  factors  which  are  to  be  noticed  in  examining  the  pulse 
are  the  frecjuency,  the  quality,  the  rhythm. 

The  frequency  of  the  pulse  is  easily  ascertained  in  general 
although  it  is  possible  for  it  to  attain  a  rate  so  rapid  as  to  be  uncouat- 
able.  The  right  radial  artery  is  chosen  for  convenience  and  the  ex- 
aminer 's  left  finger  tips  are  lightly  superimposed.  The  count  is  made 
during  fifteen  or  thirty  seconds,  unless  great  accuracy  is  desired,  when 
the  beats  are  counted  during  one  or  two  minutes.  The  normal  pulse 
rate  for  healthy  adults  is  usually  stated  as  being  seventy-two  per  min- 
ute, but  the  rate  is  sometimes  higher  and  often  much  lower.  The 
pulse  is  more  rapid  both  in  childhood  and  in  old  age,  and  varies  much 
in  different  individuals  of  the  same  age.  Eichhorst  's  figures  are  given 
thus,  slightly  modified  for  ease  in  memorizing: — first  year,  135  per 
minute;  second  year  110,  falling  to  100  at  the  fifth  year;  then  fall- 
ing two  beats  per  year  for  the  next  five  years,  giving  us  90  at  the 


.56  PHYSICAL    EXAMINATION 

tenth  year;  reaching  72  between  the  fifteenth  and  twentieth  year, 
where  the  rate  remains  stationary  nntil  the  sixtieth  year,  rising  slowly 
year  by  year  thereafter. 

Many  conditions  aside  from  disease  influence  the  pulse  rate, 
either  increasini;  or  diinini.shiug  it.  Thus  alcoholic  .stimulants  in- 
crease it  and  their  persistent  use  brings  about  a  maintained  high  pulse 
rate.  Tea  and  coffee  increase  both  the  force  and  frequency  ol'  the 
pulse,  as  does  the  taking  of  food,  while  fasting  diminishes  both.  The 
effects  of  exercise,  excitement  and  emotions  of  an  exhilarating  nature 
are  well  known,  while  depressing  emotions,  fear  and  shock  diminish  its 
rate,  as  do  rest  and  sleep.  Quiet  sleep,  recumbency,  sitting,  standing 
and  moving  each  successively  augment  the  pulse  in  the  order  named. 
High  temperatures  and  high  atmospheric  pressure  increase,  while  the 
opposite  conditions  diminish  the  rate.  Deep  breathing  and  coughing 
increase  the  volume  as  well  as  the  number  of  beats.  The  pulse  is  in- 
fluenced by  drugs,  and  it  is  wise  to  ask  what  medicines  have  been  taken 
before  estimating  the  pulse  value.  Digitalis  is  the  commonest  drug 
used  to  slow  the  heart;  belladonna  has  an  opposite  effect. 

The  pulse  during  the  twenty-four  hours  describes  two  well-defined 
■cycles  which  vary  greatly  in  different  persons,  although  showing 
■considerable  constancy  in  the  individual.  These  show  a  morning  and 
an  evening  maximum,  and  an  afternoon  and  a  night  minimum  rate. 
In  incipient  phthisis  the  day  cycle  is  often  reversed. 

Morbid  changes  which  influence  the  pulse  rate  are  too  many  to 
be  enumerated  fully,  but  a  few  may  be  mentioned  with  profit.  All 
inflammatory  conditions  and  fevers  raise  the  rate,  and  in  imcompli- 
cated  fevers  the  pulse  rate  increases  about  8  to  10  beats  for  each  de- 
gree F.  above  the  normal.  This  rule  is  not  applicable  to  persons  who 
wei'e  the  subjects  of  disease  prior  to  the  onset  of  the  fever.  In  such 
the  rate  rises  in  a  much  higher  ratio.  The  various  infective  processes, 
pyjemia,  septieasmia,  tuberculosis  and  the  like  are  all  attended  by  rapid 
pulse.  Increased  intra-thoracie  pressure  from  almost  any  cause  ac- 
celerates the  pulse,  apart  from  the  inflammatory  action  which  may 
be  the  cause  of  the  pressure;  thus  effusions,  obstructions  caused  bj' 
disease  of  lung  or  pleura,  enlarged  glands,  so  act.  In  incipient 
phthisis  the  pitlsc  constantly  augments  long  before  the  temperature 
curve  shows  its  characteristic  rise.  Pain  increases  the  rate;  so  also 
does  pneumogastric  paralysis,  as  from  glandular  or  aneurysmal  pres- 
sure.    The  rapid  pulse  of  exophthalmos  is  one  of  the  three  classic 


PHYSICAL    EXAIIINATION  0( 

symptoms  of  that  malady.    Most  anjemias  are  attended  by  rapid  pulse. 
The  technical  title  is  pulsus  frequens. 

A  diminished  pulse  rate,  while  less  frequently  a  manifestation 
■of  morbid  processes,  is  perhaps  more  significant  than  its  opposite. 
The  absorption  or  presence  in  the  blood  of  certain  substances  manu- 
factured within  the  organism,  as  urea,  bile,  bile  pigment,  etc.,  slow 
the  pulse.  Cardiac  degeneration,  especially  if  accompanied  by  dis- 
ease of  the  coronary  arteries,  some  forms  of  valvular  disease  and  affec- 
tions of  the  myocardium,  very  generally  slow  the  pulse.  Of  the  valve 
lesions,  aortic  stenosis  stands  first  in  this  relation,  followed  by  mitral 
stenosis.  All  forms  of  weakness,  especially  post-febrile  and  post- 
hemorrhagic debility,  influence  the  rate  in  the  same  manner.  A  large 
percentage  of  epileptics,  as  pointed  out  by  Craig,  are  the  subjects 
•of  valvular  heart  diseases ;  but  aside  from  this  they  furnish  a  pulse 
rate  most  striking  for  its  slowness.  Wood  records  a  rate  of  8  to  10 
per  minute.  All  forms  of  disease  of  the  brain  and  meninges  accom- 
panied by  increased  intercerebral  pressure,  retard  the  pulse.  Lead 
intoxication  slows  the  pulse.  Many  other  conditions  wiU  also  fall 
within  the  experience  of  the  practitioner.  The  condition  is  spoken  of 
as  pulsus  rarus,  but  in  extreme  slowness  the  precaution  of  counting 
the  systolic  contractions  of  the  heart  always  should  be  observed,  as  the 
wave  may  not  reach  the  extremity. 

The  quaUtj'  of  the  pulse  depends  upon  the  balance  maintained 
hetween  its  size,  its  strength  and  its  fullness.  The  amount  of  expan- 
sion which  the  arterj-  undergoes  depends  iipon  the  strength  and  the 
fullness.  The  strength  varies  with  the  strength  of  the  cardiac  con- 
traction, and  the  fuUness  with  the  amount  of  fluid  pumped  into  the 
channels.  The  latter  is  much  influenced  by  the  state  of  the  venous 
system.  "Without  material  difference  in  the  rate  the  artery  may  swell 
gradually  under  the  finger,  or  the  vessel  may  fill  with  unwonted  sud- 
denness, to  subside  as  quickly  as  it  arose.  Such  conditions  often  point 
to  organic  diseases  of  the  valves. 

The  last  described  of  these  conditions,  spoken  of  as  the  pulse  of 
unfilled  arteries,  the  recedent  pulse,  or  puisnes  celer,  often  enables  lis 
■definitely  to  recognize  aortic  incompetency.  The  peculiarity  is  made 
more  strikingly  manifest  if  the  patient's  arms  are  raised  vertically 
above  his  head  while  examining  the  radials.  With  this  pulse  is  often 
seen  marked  pulsations  in  the  vessels  of  the  neck  and  elsewhere.     It 


58  PHYSICAr.    EXAMINATION 

is  called  Corrigan's  pulse,  from  its  deseriber.  Its  sudden,  slapping, 
jerky  character  has  piven  it  the  name,  "water-hanuner  pulse." 

States  of  high  arterial  tension  give  us  a  hard,  full  pulse.  The 
vessel  walls  are  not  hard,  yet  the  pulse  may  have  a  cord-like  feel.  The 
radial  pulse  may  be  misleading,  as  it  is  sometimes  anomalous,  and  is 
easily  pressed  upon  by  clothing. 

We  estimate  the  strength  of  the  pulse  by  the  amount  of  pressure 
of  the  fingers  necessary  to  obliterate  it.  A  really  weak  pulse  is  ac- 
companied by  a  diminution  in  intensity  of  the  first  sound  of  the  heart, 
without  much  change  in  the  intensity  of  the  second  sound.  Obstruc- 
tion in  front  as  well  as  increase  of  the  vis-a-tcrgo  give  us  a  hard  pulse, 
hence  mitral  stenosis,  aortic  insufficiency,  contracted  kidneys,  hepatic 
cirrhosis  and  many  other  conditions  produce  it.  The  distinction  be- 
tween a  hard  pulse  and  hardness  of  the  arterial  coats  due  to  sclerosis, 
should  be  borne  in  mind.     The  differentiation  is  simple. 

Puhc  Rhythm.  In  health  the  pulse  is  perfectly  regular.  How- 
ever, during  sleep,  especially  in  children,  intermissions  may  occur 
which  are  in  no  wise  due  to  deleterioiis  infliiences.  The  .study  of  the 
pulse  often  shows  a  distinct  intermission  recurring  at  regular  inter- 
vals, as  the  loss  of  a  beat  at  every  fourth,  sixth  or  eighth  contraction ; 
or  the  intermission  may  be  irregular.  The  pulse  may  be  affected 
without  the  heart  being  correspondingly  involved,  or  the  heart  beat 
also  may  be  abortive.  Sometimes  several  slow  pulse  beats  are  fol- 
lowed by  two  or  three  rapid  ones.  The  significance  varies  greatly. 
Excessive  use  of  tobacco  is  one  of  the  most  conuiion  causes  of  arythmie 
pulse.  Arhythmia  is  sometimes  a  premonition  of  oncoming  cerebral 
disturbances.  It  is  common  in  pericarditis,  especially  of  children,  and 
in  many  forms  of  heart  disea.se,  particularly  fatty  heart,  of  which  it 
is,  perhaps,  the  most  pronounced  sign,  of  mitral  disease  and  various 
functional  disturbances,  as  flatulency  or  dyspepsia.  It  is  prone  to 
occur  during  convalescence  from  debilitating  diseases,  where  its  sig- 
nificance is  less  ominous  than  its  occurrence  during  the  height  of  the 
ailment,  when  it  often  portends  heart  failure. 

The  pulse  of  the  two  sides  may  show  want  of  symmetry,  as  often 
occurs  in  aneurysm  of  the  arch  of  the  aorta  causing  obstruction  of 
some  of  the  branches.  Owing  to  the  same  cause  the  two  pulses  may 
not  be  perfectly  synchronous.  Embolism  may  cause  diminution  or 
obliteration  of  the  pulse,  but  in  such  cases  a  careful  search  for  anoma- 
lies should  be  made. 


PHYSICAL    EXAMINATION  59 

THRILL. 

In  mitral  and  aortic  disease  a  distinct  thrill  is  sometimes  imparted 
to  the  pulse,  and  should  always  suggest  the  causative  factor. 

Dicrotous  Pulse  and  Pulsus  Bigeminous.  Sometimes  a  curious 
double  beat  may  be  felt  by  applying  the  fingers  very  lightly  over  the 
artery.  It  is  not  uncommon  during  convalescence  from  fevers,  espe- 
cially typhoid.  When  the  two  beats  follow  each  other  closely,  it  is 
called  "bigeminous";  generally  the  second  beat  is  weaker.  The 
sphygmograph  more  clearly  shows  these  peculiarities.  Its  significance 
is  not  particularly  important. 

VASCULAR  PHENOMEINA. 

A  study  of  the  various  phenomena  exhibited  by  the  veins  and 
arteries  is  both  interesting  and  profitable  although  much  neglected  by 
the  student  in  general. 

The  veins  from  the  examination  of  which  may  be  gained  most 
information  are  those  of  the  neck,  especially  the  internal  and  external 
jugulars,  although  the  superficial  veins  of  the  chest,  abdomen,  legs> 
and  other  parts  are  capable  of  imparting  many  supplemental  facts. 
The  phenomena  presented  are  studied  by  inspection,  palpation,  and 
auscultation. 

I.  Venous  Pulsation.  On  inspection  there  is  often  present  a 
visible  throbbing  in  the  veins  of  the  neck,  the  internal  and  external 
jugulars  being  especially  the  seat  of  pulsation.  By  reason  of  the 
direct  connection  with  the  superior  vena  cava,  the  right  internal  jugu- 
lar is  more  apt  to  show  pulsation  than  its  fellow.  The  significance  of 
the  venous  throb  in  the  neck  has  been  referred  to  under  cardiac  in- 
spection. The  vente  innominatte  or  brachio-cephalic  sinuses  at  the 
root  of  the  neck,  just  behind  the  clavicle,  should  be  carefully  exam- 
ined.   Palpation  may  reveal  pulsations  which  are  invisible. 

II.  Enlargement  of  the  veins  is  of  common  occiirrence  and  may 
be  temporary,  permanent,  variable  or  intermittent.  Kinking,  knotting 
and  varicosities  are  present.  They  are  far  more  common  in  women 
than  in  men,  and  become  more  apparent  with  the  advance  of  age. 
Permanent  enlargement  of  the  veins  results  from  dilatation  or  con- 
tinued engorgement  of  the  right  heart,  from  tricuspid  regurgitation, 
from  obstruction  affecting  a  large  venous  channel  as  the  cava.  Such 
obstruction  may  be  caused  by  extreme  pressure  from  an  enlarged 
organ,  as  occurs  in  hepatic  cirrhosis,  by  a  new  growth,  such  as  a  tumor 


60  PHYSICAL    EXAMINATION 

or  an  aneurysm,  or  from  occlusion  of  the  vascular  lumen  by  a  throm- 
bus or  an  embolus.  The  enlargement  may  be  due  to  the  communica- 
tion of  an  aneurysm  with  the  superior  cava,  of  which  accident  Pepper 
and  Griffith  have  collected  twenty-nine  cases.  "Cyanosis,  oedema  and 
great  distention  of  the  veins  of  the  upper  part  of  the  body,  being  the 
most  frequent  symptoms." 

Thrombosis  of  the  portal  vein  may  occur  as  a  sequence  of  cirrhosis 
or  syphilis  of  the  liver,  or  be  caused  by  cancer  or  by  sclerosis  of  the  vein 
itself.  The  condition  is  known  as  adhesive  pylephlebitis.  Intense 
engorgement  of  the  entire  portal  system  rapidly  follows.  The  super- 
ficial abdominal  veins  ai'e  distended  and  tortuous.  ILpinatemesis, 
meltcna,  ascites  and  enlargement  of  liver  and  spleen  give  intimations 
of  the  condition.  A  definite  diagnosis  is  rarely  reached  during  life. 
The  distention  of  the  cervical  veins  during  cough  is  a  familiar  spec- 
tacle, but  during  the  course  of  diseases  which  permanently  enlarge  the 
veins,  and  thus  produce  insufficiency  of  the  valves,  the  swelling  is  much 
increased  during  the  act  and  even  may  be  alarming,  as  in  a  recent  case 
of  my  own  of  a  patient  in  the  terminal  stages  of  phthisis.  In  extreme 
cases  the  pulsation  can  be  both  seen  and  felt.  An  easy  method  of  de- 
termining whether  the  pulsation  is  transmitted  or  is  due  to  filling 
from  below  is  to  make  just  sufficient  pressure  on  the  vein  to  obliterate 
its  lumen  at  its  lowest  palpable  point  in  the  neck,  then  to  slide  the 
finger  upwards  for  a  short  distance  with  only  sufficient  force  to  empty 
the  vessel.  If  the  vessel  fills  from  below  it  does  so  with  a  jerk  which 
is  synchronous  with  systole  and  the  carotid  pulse.  The  external  jugu- 
lar ofliers  the  best  opportunity  for  the  trial. 

Venous  distention  increases  during  expiration  and  diminishes 
during  inspiration.  As  already  mentioned,  tricuspid  regurgitation 
and  right-sided  engorgement  and  hypertrophy  are  the  most  potent 
causes  of  the  phenomena.  Insufficiency  of  the  valves  within  the  veins 
has  been  discussed.  Friedreich 's  diastolic  collapse  as  a  sign  of  pericar- 
dial adhesion  is  described  elsewhere.  Venous  pulsation  is  often  seen  in 
chorea  and  chlorosis.  The  venous  engorgement,  particularly  of  the 
small  veins  of  the  thorax,  in  emphysema  is  mentioned  thereunder. 

Most  cardiac  valvular  diseases,  especially  when  accompanied  by 
lack  of  compensation,  produce  venous  engorgement,  of  which  local  and 
general  cedemas  are  the  sequels. 

The  enlargement  of  the  veins  around  the  umbilicus,  known  as  the 


PHYSIC.Ui    EXAMINATION  61 

caput  medusa,  is  due  to  thrombosis  or  obliteration  of  the  portal  vein, . 
as  occurs  in  cirrhosis  of  the  liver. 

In  phthisis  venous  pulsations  are  common,  an  occasional  situation 
being  the  back  of  the  hand. 

VENOUS  MUR]\rURS. 

Auscultation.  The  "bruit  de  diable"  of  French  writers, the  venous 
hum  of  American  authors,  is  often  present  in  health,  but  is  generally 
accepted  as  significant  of  anajmia  wherein  its  intensity  furnishes  an 
index  of  the  grade  of  the  ana?mia  for  the  particular  case ;  that  is  to  say, 
that  while  it  varies  widely  in  the  different  forms  of  anfemia,  and  in 
different  individuals,  yet  in  general  its  intensity  lessens  with  improve- 
ment and  increases  with  increase  in  the  malady. 

The  bruit  is  best  heard  at  the  junction  of  the  right  subclavian 
with  the  jugular  vein,  the  head  being  twisted  slightly  to  the  opposite 
side.  The  murmur  is  not  interrupted  as  is  the  arterial  murmur,  but  is 
continuous.  Its  quality  varies  and  the  names  descriptive  thereof  are 
as  numerous  as  those  chosen  to  describe  valvular  lesions.  It  is  usually 
humming  or  buzzing,  or  rustling,  but  may  be  musical,  singing,  piping 
or  whistling.  Pressure  of  the  stethoscope  produces  it  in  health  and 
pressure  intensifies  it  when  otherwise  present.  It  is  strongest  during 
inspiration  and  during  cardiac  systole.  It  diminishes  and  may  disap- 
pear on  lying  down  and  is  loudest  when  the  patient  is  erect.  Some- 
times a  venous  thrill  is  felt  in  the  vessels  of  the  neck  in  cases  of 
extreme  ansemia,  but  is  quite  rare. 

Time  of  Venous  Pulsations.  The  venous  pulse  as  observed  in  the 
external  jugular  is  either  presystolic  or  systolic.  It  may  be  timed 
by  the  carotid  pulse.  The  presystolic  pulsation  is  spoken  of  as  the 
negative  pulse.  The  vein  collapses  with  the  heart's  systole  and  refills 
before  the  next  systole.  The  collapse  is  synchronous  with  the  apex 
beat,  hence  the  refilling  is  synchronous  with  the  auricular  contraction 
which  closes  diastole  and  is  presystolic. 

The  systolic  venous  pulse,  spoken  of  as  the  positive  pulse,  is 
synchronous  with  the  apex  beat.  It  is  most  apparent  in  the  right 
internal  jugular  vein  and  is  a  very  important  and  positive  sign  of 
tricuspid  regurgitation.  To  a  lesser  degree  other  veins  are  affected 
and  show  throbbing.  In  the  form  of  valvular  deficiency  just  men- 
tioned this  pulsation  is  produced  by  the  systole  of  the  right  ventriek 
projecting  a  current  of  blood  through  the  insufficient  tricuspid  valve 


62  PHYSICAL,    EXAMINATION 

at  each  contraction,  over-distending  the  already  filling  auricle  and 
projecting  the  blood  still  farther  into  the  ascending  cava  whose  open 
mouth  is  unguarded  by  valves. 

A  similar  blood  wave  traverses  the  inferior  cava  and  gives  rise 
to  pulsations  in  the  liver  produced  and  explained  in  the  same  manner 
and  having  the  same  time  as  the  jugular  pulsations.  The  change  in 
the  volume  of  the  organ  which  occurs  with  expansion  and  contraction 
of  the  heart  may  sometimes  be  distinctly  felt  and  even  seen.  Ofttimes 
the  throbbings  are  painful. 

The  phenomenon  is  best  appreciated  by  placing  one  hand  over  the 
fifth  and  sixth  interspaces  at  the  junction  of  the  costal  cartilages  and 
the  other  over  the  liver  in  the  mid-axillary  line,  when  the  rhythmic, 
systolic  expansile  pulsation  is  felt  easily  and  can  be  distinguished 
readily  from  the  systolic  depression  of  the  liver  caused  by  communi- 
cated pulsations  from  the  hypertrophied  right  ventricle,  which  is  non- 
expansile. 

ARTERIAL  :\IUR]\rURS. 

Through  the  large  arteries  the  sounds  of  the  heart  are  transmitted 
for  a  considerable  distance  by  the  blood  current  and  have  the  quali- 
ties of  the  sounds  as  heard  at  the  aortic  valves.  The  intensity  dimin- 
ishes as  would  be  supposed  as  we  recede  from  the  point  of  origin.  In 
the  neck  over  the  seat  of  the  common  carotids  or  the  subclavian  artery 
both  heart  sounds  are  distinct,  but  the  sound  made  by  the  closure  of 
the  aortic  valve,  the  cardiac  second  sound,  is  the  more  e^•ident.  The 
first  heart  sound  is  here  faint  and  of  low  pitch. 

Over  the  exit  of  the  femoral  arteries  from  under  Poupart's  liga- 
ment the  aortic  valve  sound  may  often  be  distinguished  in  health,  but 
disappears  before  Hunter's  canal  is  reached.  At  the  ligament  the 
first  heart  sound  can  not  be  heard. 

Arterial  Miinmiis  due  to  Disease.  Just  as  pressure  with  a  steth- 
oscope upon  the  trunk  of  an  artery  causes  a  murmur  to  appear,  so 
pressure  arising  from  various  causes  as  tubercular  deposits,  new 
growths,  enlarged  glands,  thjToid  tumors  or  aneurysms  occasion 
arterial  murmurs. 

Diseases  of  the  vessels  which  change  their  caliber  or  destroy  the 
resiliency  of  their  coverings  produce  murmurs,  hence  the  aneurysmal 
bruit  and  the  murmur  a.s.sociated  with  extensive  atheroma.  This  dis- 
ease is  prone  to  attack  the  aorta  just  beyond  the  sinuses  of  Valsalva, 


PHYSICAL    EXAMINATION  63 

and  many  a  case  of  supposed  aortic  valvular  disease  is  in  reality  due 
to  the  bruit  or  the  thi-iU  caused  by  the  calcification  plates.  Congenital 
narrowing  of  the  vessels  operates  in  the  same  way  as  external  pressure 
to  produce  bruits.  Thrombosis  may  also  cause  a  murmur.  The  uter- 
ine bruit  which  accompanies  the  formation  of  the  placental  sinuses 
during  pregnancy  is  a  familiar  example  of  vascular  murmur. 

In  aortic  insufficiency  the  vascular  phenomena  are  characteristic 
and  it  is  possible  to  make  a  diagnosis  of  the  disease  by  inspection 
and  palpation  alone.    Thus : 

On  Inspection  a  visible  pulsation  is  seen  in  the  peripheral  vessels, 
artei-ies,  veins  and  capillaries,  and  often  the  face  or  hands  are  seen 
to  alternately  suffuse  and  pale  with  the  heart  action.  The  capillary 
pulse  is  seen  in  the  linger  nails  or  along  the  margins  of  a  light  scratch, 
or  by  pressing  a  microscopic  slide  against  the  everted  mucous  mem- 
brane of  the  lower  lips,  as  suggested  by  Shattuck.  The  arteries  pul- 
sate forcibly,  the  carotids  swell  and  throb,  the  aorta  behind  the  supra- 
sternal notch  rises  and  suggests  aneurysm,  the  abdominal  aorta  lifts 
the  epigastrium  with  each  beat.  The  temporals  and  radials  fill  with  a 
vermicular  twist  and  jerk,  followed  by  instant  collapse.  The  ophthal- 
moscope shows  the  same  phenomena  in  the  retinals. 

Palpation.  The  finger  feels  a  short,  quick,  hammer-like  stroke, 
followed  by  rapid  recedence.  When  timed  with  the  apex  beat  the 
radial  pulse  shows  a  distinct  retardation. 

Auscidtation.  In  the  carotids  and  subclavians  a  double  murmur 
is  heard,  and  the  second  aortic  sound  may  be  audible  here,  even  when 
absent  at  the  aortic  cartilage.  Duroziez  calls  attention  to  the  double 
murmur  heard  in  the  f emorals. 

Tyson  mentions  a  vascular  sign  described  by  Traube,  occurring  in 
aortic  regurgitation  as  the  result  of  the  sudden  change  of  pressure. 
' '  This  is  usually  a  double  sound,  of  which  the  first  element  is  ascribed 
to  the  rapid  distention  of  the  artery  by  a  blood  wave  which  throws  its 
walls  into  -vibration.  A  second  sound  occurs  with  a  cessation  of  the 
pressure. ' ' 

Intermittent  venous  murmurs  are  spoken  of  by  some  authors; 
they  must  be  of  rare  occurrence. 

THE  SPHYGMOGRAPH. 

Numerous  instruments  have  been  devised  for  the  graphic  repre- 
sentation of  the  pulse  in  the  human  being.  Marey's  sphygmograph 


64 


PHYSICAL    EXAMINATION 


is  one  of  the  oldest,  but  is  still  most  used.  Riehardsou's  ov  Dudgeon's 
modification  of  Ponds'  American  sphygmograph  is  the  simplest  form 
for  the  clinician.  By  means  of  the  instrument  a  graphic  record  of 
the  pulse  is  made  in  the  form  of  a  tracing,  which  shows  a  saw-like 
series  of  elevations  and  depressions  corresponding  to  the  vibrations  in 
the  pulse  wave. 

The  elevations  correspond  to  the  onset  of  the  wave,  the  depres- 
sions to  its  recedenee.  Hence  variations  in  the  tracing  graphically 
show  differences  in  the  temporary  rise  and  fall  of  arterial  pressure, 
the  rate  at  which  successive  waves  pass  a  given  point,  as  well  as  varia- 


Fig.  i8 — Dudgeon's   SpIi3-gniograph. 

tions  in  their  rhythm.  The  primary  blood  wave,  caused  by  the  cardial 
systole  is  followed  by  several  succeeding  waves  of  lesser  degree,  called 
secondary  waves.  The  chief  of  these  is  the  rebound  in  the  blood  cur- 
rent caused  by  the  sudden  check,  produced  by  the  closure  of  the  aortic 
valves,  named  the  dicrotic  wave.  A  lesser  wave,  supposed  to  be  due 
to  the  stoppage  of  the  backward  flow  towards  the  heai-t  of  the  aortic 
current,  by  the  closure  of  the  valves,  is  called  the  predicrotic  wave. 
Perhaps  the  following  explanation  will  render  clear  the  difference  in 
the  two  waves.  The  systole  forces  the  current  up  hill  into  the  aorta. 
A  portion  of  the  fluid  obeys  the  impulse  to  return.  The  gates  close. 
The  first  influence  felt  by  the  column  in  the  arteries  is  the  stoppage — 
the  predicrotic  wave.  The  second  effect  is  the  rebound — the  dicrotic 
wave.  This  dicrotic  wave  is  increased  by  the  natural  resilient  recoil 
of  the  elastic  aortic  walls,  dilated  by  the  primary  current,  which 
occurs  just  in  time  to  catch  the  second  wave.  Lesser  waves  due  to 
ihis  resiliencv  follow  the  dicrotic  wave  but  are  of  less  moment. 


PHTSIG.VL    EXAMINATION 


65 


The  dicrotic  iiotclt  is  due  to  the  cessation  of  the  inflow  with  each 
sj-stole,  causing  a  momentary  falling  oft'  of  the  pressiire.  the  fall  being 
modified  by  the  infliiences  just  named. 

When  the  arterioles  are  constricted,  the  dicrotic  notch  is  lessened 
and  we  have  the  curve  of  high  tension,  pulse  such  as  occurs  in  Bright 's 
disease.  When  the  arterioles  are  widely  dilated,  the  dicrotic  notch  is 
exaggerated  and  we  have  the  low  tension  characteristic  curve.  Before 
making  the  tracing  it  is  well  to  measure  the  varying  degrees  of  pulse 
tension  by  the  sphygmometer.  The  pressure  of  the  instrument  is  ad- 
justed accordingly.    In  pulse  of  low  tension,  slight  pressure  gives  the 


tL       u        ^ : 


ANACROTIC 


PflSE. 


catacrotic 
side: 


a     b    c    ti 

,    19 — Normal  pulse  tracing. 


best  results  and  too  much  pressure  extinguishes  the  tracing.  In  high 
tension  pulse,  rather  strong  pressure  of  the  spring  button  gives  the 
best  results. 

Ax.  entrance  of  the  stream  into  the  aorta.  This  up-stroke  is  called 
the  anacrotic  stroke,  or  percussion  stroke,  and  is  due  to  the  sudden 
•dilatation  of  the  artery  by  the  primary  blood  wave.  The  hypersensi- 
tive lever  is  carried  too  high,  and  in  reality  should  have  stopped  at  x. 
The  lever  begins  to  fall  but  is  overtaken  by  the  predicrotic  wave  on 
the  cataerotic  side  of  the  tracing  and  carried  to  y — ,  the  real  summit 
■of  the  pulse  wave.  Hence  omitting  the  false  movement  of  the  lever, 
axy.  represents  the  real  upward  or  anacrotic  curve,  ky,  represents  the 
predicrotic  notch,  y.  represents  the  point  at  which  the  ventricular 
stream  ceases,  when  the  positive  pressure  remits  and  the  negative 


bti  IMIYSICAl.    EXAMINATION 

wave,  caused  by  the  sudden  cessation  of  iutlowiutr  blood,  and  the  first 
slifrht  reflux  betrins.  This  cessation  of  pressure  allows  the  lever  to  fall 
to  «'.  ^V.  is  the  point  of  closure  of  the  aortic  valves  and  is  synchronous 
with  the  second  sound  of  the  heart.  Wz.  is  the  positive  wave  or  re- 
bound due  to  the  closure  of  the  aortic  valves  and  corresponds  to  the 
true  dicrotic  wave,  hence  ijwz.  is  the  dicrotic  notch,  sometimes  called 
the  aortic  notch,  owin?  to  the  manner  of  its  production.  The  slight 
curve  at  m,  is  due  to  the  resilient  waves  which  succeed  the  aortic  or 


A 

Fig.  20 — Pulse  of  constricted  arterioles.     High  tension  pulse. 

dicrotic  wave.     Since  this  curve  m,  is  produced  durinfr  diastole,  it  is 
sometimes  caled  the  diastolic  notch. 

The  Pulse  of  High  Arterial  Tension.  The  pulse  of  constricted 
arterioles,  the  hitrh  tension  arterial  pulse,  called  by  Sansom  the  pul.se 
of  prolonged  arterial  tension,  differs  from  the  normal  pulse  in  that  a 
notch  is  formed  at  the  top  of  the  curve  and  the  ma.ximum  altitude  of 
the  lever  may  be  reached  after  the  notch.  Yeo  explains  this  phenom- 
enon on  the  groimd  that  the  first  reflected  wave  is  positive  instead  of 
negative,  in  the  case  of  constricted  arterioles,  and  is  therefore  added 
to  the  percussion  stroke,  reaching  it  .just  as  the  lever  begins  to  fall  at  k 
Tiid  carrying  it  to  ij,  thus  broadening  the  top  of  the  primary 
"iirve,  and  this  pulse  is  named  the  anacrotic  pulse.  The  aortic  or 
■dicrotic  notch,  wz.  is  lessened  as  the  dicrotic  wave  is  lessened  in  these 
conditions  and  the  post-dicrotic  wave  nt.  is  not  discernible.  Such  a 
pulse  is  the  result   of  i-esistance   encountered   by  the   lilood   current 


PHYSia\L    EXAMINATION  67 

through  the  arterioles  and  capillaries,  as  stated,  and  is  found  in  con- 
tracted kidneys,  in  all  diseases  which  cause  atheroma  of  the  arterial 
walls,  gout,  lead-poisoning,  and  aortic  stenosis. 

Lead-poisoning  is  prone  to  produce  three  of  the  chief  disease-fac- 
tors just  mentioned,  since  lead  workers  are  notoriously  subject  to 
arterio-sclerosis,  contracted  kidneys  and  hypertrophy  of  the  heart.  In 
this  state  the  fullness  of  the  vessels  is  felt  to  be  maintained  for  a  con- 
siderable period  and  the  collapse  is  gradual.  Pressure  of  the  finger 
obliterates  the  pulse  with  difificuUy. 

The  Pulse  of  Low  Arterial  Tension.  In  this  case  the  arterioles  are 
widely  dilated,  the  negative  wave  is  reflected  and  is  subtracted  from 
the  primary  wave  instead  of  being  added  to  it.     The'Vessels  collapse 


A 

Fig.  21 — Pulse  of  low  arterial  tension. 

quickly  after  the  primary  filling  aud  pressure  of  the  finger  easily  oblit- 
erates the  pulse.  Such  a  pulse  is  said  to  be  soft.  The  tracing  shows  a 
vertical  up-stroke,  ak,  followed  by  a  quick  fall,  ky,  so  that  the  apex,  h, 
is  sharp  and  pointed.  The  predicrotic  notch,  y,  is  insignificant,  but  the 
dicrotic  notch,  wz,  and  aortic  wave,  z,  caused  by  the  valve  closure  are 
exaggerated,  also  the  post-aortic  curve,  m,  is  marked.  When  present 
in  even  a  moderate  degree  the  wave,  z,  may  be  appreciated  by  palpa- 
tion and  the  pulse  is  said  to  be  dicrotic.  Such  dicrotism  may  reach  an 
extreme  degree  and  the  point,  w,  may  fall  to  the  base  line  or  below,  in 
which  case  the  pulse  is  said  to  be  hyperdicrotic. 

Low  tension  pulse  occurs  with  conditions  which  cause  dilatation 
of  the  capillaries,  as  the  inhalation  of  chloroform,  the  administration 
of  nitro-giycerine  or  nitrite  of  amyl.  Turkish  baths  are  followed  by 
the  low  tension  pulse.  In  diseases  producing  serous  diarrhoeas,  colli- 
quative sweats  and  diuresis  it  follows,  owing  to  the  emptying  of  tlu' 
vessels.    It  often  marks  the  course  of  febrile  diseases.    Aortic  regurvi- 


68 


I'lIYSICAI.    EXAM  INATIUN 


tation  furnishes  tlw  best  examples.  When  the  dicrotic  wave  ap- 
proaches in  force  to  equality  with  the  primary  w^ave,  to  the  tinj<er  it 
appears  as  thouf;h  there  were  two  closely  associated  beats  followed  by 
a  pause.  Such  a  pulse  is  called  pulsus  bi<reniinus.  (See  section  on 
Pulse.) 

Sometimes  three  such  beats  are  separated  by-  a  ])ause  when  the 
name  pulsus  tri<reminus  is  used  to  desifrnate  the  condition. 

THE  SPIIYCI.MO.METER. 

This  is  an  instinnnent  intended  to  measure  the  decree  of  tension  in 
the  peripheral  artci-ies  with  iireater  accuracy  tliiin   tin-  time  hdiinrcd 


Fig.  J2 — The  Riva  Rocci  Sphygmomanometer. 

one  of  simple  palpation.  By  its  use  records  can  be  made  of  daily 
\'ariations  during:  the  course  of  disease  and  operations,  as  well  as  the 
ascertainintr  of  immediate  results  from  taking  medicine,  food,  and 
drink. 

A  number  of  these  instruments  have  been  devised,  some  supposed 
to  measure  the  systolic  pressure  of  the  artery,  by  recording  the  amount 
of  force  required  to  obliterate  the  pulse,  others  to  measure  diastolic 
pressure.  The  recorders  are  of  two  kinds,  manometers,  or  mercurial 
columns,  and  aneroid  instruments,  fitted  with  dials,  like  the  barometer. 
The  latter  are  ob.jectionable  owing  to  the  readiness  with  which  their 


PHYSIC.U.    EXAMINATION  69 

mechanism  is  disordered.  The  objection  to  the  instruments  in  general 
is  that  they  are  provided  with  rubber  tubing  which  inflates  to  vary- 
ing degrees  under  pressure  and  changes  much  in  this  respect  with  age. 
The  Riva-Rocci  instrument  is,  all  things  considered,  the  most 
serviceable.    Stanton,  of  the  University  of  Pennsylvania,  has  modified 


Fig.  23 — The   Riva-Rocci   Sphygmometer — Stanton   modification.     A   Air   pump. 
B  Manometer.     C  Cuff. 

this  by  fitting  it  with  rigid  connections.  The  essential  parts  are  an 
air  pump,  a  manometer,  a  rubber  armlet  which  fits  around  the  upper 
arm,  and  tubing  connections.  Stanton  advises  that  the  width  of  the 
armlet  be  not  less  than  three  and  a-quarter  inches.  To  use  the  instru- 
ment the  armlet  is  adjusted,  air  is  pumped  in  until  the  radial  pulse  is 
exactly  extinguished,  and  the  height  of  the  mercury  noted  at  the  same 
moment.  Experiments  have  shown  that  the  pressure  within  the  arm- 
let and  that  within  the  manometer  are  at  all  times  the  same.  The 
fiecuracy  of  the  instrument  is  shown  by  applying  it  to  the  thigh,  when 


70  IMIVSICAl.     KXAMINATION 

it  will  be  I'ouiul  tlial   tin-  dilTViciu-i'  in  llic  iiulrx  d.u's  not    \i\yy  ovci- 
four  or  five  millimeters. 

The  sli<iht  oscillations  noticed  aie  caused  l)y  the  varyin';-  ile!.nve  of 
iiiterarterial  pressure  and  the  intiuence  of  respiration  on  blood  pres- 
s\ire.  Durinjr  the  course  of  protracted  operations  the  instrument  fur- 
nishes valuable  information,  likewise  in  llir  study  of  tlw  state  of 
jirterial  tension  in  kidney  and  heart  diseases,  iind  the  dVect  n\'  di-niis. 
It  is  difficult  to  trnnsport.  is  fragile  and,  like  many  other  dcvircs.  has 
so  far  found  its  lichi  ol'  threat 'st  usefulness  in  tlic  hos|iital. 


PERCUSSION. 

Pereussion  elicits  cei-tain  sounds  hy  tapping:  over  thi 


areas  occu- 


lii'd   bv   the   thoraeie   and   abdominal   oi'-ans.      'I'h-   tappiuL:    may    be 


I'i.y.  24 — PerciLSsion    Haiiiincr. 

ilirectly  upon  the  overly inp;  tissues,  called  mediate,  or  upon  an  im- 
posed substance,  immediate.  While  the  rubber-headed  hammer  named 
a  plessor,  and  an  ivory  plate  called  a  pleximeter,  are  useful  for  class 
demonstrations,  nothing  in  actual  practice  equals  the  fingers  of  the 
two  hands,  as  thereby  we  not  only  quite  as  satisfactorily  elicit  the 
sounds  sought  for,  but  further  gain  valuable  information  by  noting  the 
amount  of  resistance  which  the  finger  encounters,  and  likewise  the 
amount  and  length  of  the  vibrations  communicated  to  the  super- 
imposed digit.  Percussion  is  the  most  diffictilt  to  acquire  of  the  arts 
used  in  physical  diagnosis,  and  the  maxim  that  "practice  makes  per- 
fect"" is  peculiarly  applicable  here.  The  stroke  should  be  delivered 
from  the  wrist,  as  in  piano-playing;  never  from  the  elbow.  The  ham- 
mer fingers  should  fall  perpendicularly  and  strike  the  finger  which  is 
iised  as  pleximeter  at  a  right  angle  to  its  surface,  while  the  latter  is 
applied  as  firmly  and  as  evenly  to  the  chest  wall  as  possible.  For  per- 
cussing, the  middle  and  third  fingers  are  superior  to  the  index  and 
middle  fingers.  The  nails  should  be  kept  short,  that  they  do  not  pro- 
duce sounds  by  impact.  In  percussing  over  the  thorax  the  fingers 
should  be  applied  to  the  intercostal  spaces  parallel  with  the  ribs,  never 
across  the  rib  and  interspace,  since  this  gives  two  notes  diff'ering  in 


PHYSICAL    EXAMINATION  I  i 

quality.  Over  the  clavicle,  mediate  percussion  gives  the  best  result 
and  often  gives  the  earliest  indication  of  disease  by  a  variation  from 
the  normal  note.  Oiring  to  varying  conditions,  such  as  thickness  of 
the  overlying  muscular  tissues,  quantity  of  fat  present,  etc.,  the  sounds 
elicited  by  percussion  over  the  lungs  vary  greatly  not  only  in  differ- 
ent areas  upon  the  individual,  but  likewise  over  corresponding  areas 
in  different  individuals:  so  much  so  that  we  are  not  far  wrong  in 
saying  that  every  lung  has  its  own  normal  note. 

PEECUSSIOX  SCALE. 

In  spite  of  these  variations,  we  may  construct  a  rough  scale  which 
is  generally  applicable,  although  the  notes  lack  the  fixedness  of  musi- 
cal tones.  The  note  of  highest  pitch  is  obtained  by  direct  percussion 
over  a  bone,  as  the  sternum  or  clavicle,  and  is  called   osteal  pitch. 


Fig.    25 — Ple.ximeter. 

Next  is  the  tone  produced  by  percussion  over  the  trachea  during  quiet 
inspiration.  This  is  called  tubular  pitch.  The  note  produced  by  per- 
cussion over  the  second  anterior  interspace  or  the  axilary  region  of  a 
healthy,  well-developed  individual  falls  next  in  the  scale,  and  this 
note  is  called  the  vesicular  note  or  the  normal  pulmonary  note.  Flint's 
comparison  of  this  note  to  that  produced  by  tapping  a  large  loaf  of 
bread  is  classic.  The  note  produced  by  percussion  over  an  air-con- 
taining ca^dty  of  considerable  size,  as  the  stomach  and  intestine,  is 
called  tympanitic.  It  is  lower  in  pitch  than  the  vesicular  note.  It  i.^. 
not  difficult  to  divide  tympanitic  resonance  into  two  tones,  small 
tympany,  the  note  of  the  small  intestine  furnishing  the  standard 
therefore,  and  large  tympany,  the  latter  being  the  note  obtained  by 
percussion  over  the  empty  stomach  or  the  colon.  The  note  which 
Flint  called  vesiculo-tympanitic  occurs  in  disease,  but  in  the  scale  of 
pitch  assumes  a  place  between  the  normal  vesicular  resonance  and 
small  tjTnpany. 

Two  other  sounds  remain  to  be  considered,  dulhiess  and  flatness. 
Gee  defines  dullness  as  the  absence  of  tone,  tone  being  that  succession 
f>f  sound  impulses  which  characterizes  a  musical  tone,  but  which  is 


,2  I'JIYSICAL    KXAMINATION 

absent  iu  a  mere  noise.  Ca  Costa*  defines  a  dull  sound  as  one  denoting 
the  absence  of  air.  "It  is  the  sound  of  both  tiuids  and  solids.  It  is 
thus  the  sound  sent  forth  by  the  airless  viscera :  from  the  liver,  spleen 
and  heart.''  We  believe,  however,  that  a  profitable  distinction  can  be 
made  between  dullness  and  flatness  by  calling  the  sound  possessing 
the  above  qualities  tiat,  and  calling  a  sound  which  approaches  Hatness 


Fig.  26 — Percussion  of  dorsal  regions.     Patient  astride  of  chair  with  arms  folded 
across  tlie  hack.     Intercostal  spaces   widened,  scapiilfe  rotated  outward. 


in  iiitch,  but  which  still  retains  some  resonance,  dull.  In  the  scale  of 
pitch,  the  terms  would  fall  above  osteo-piteh.  flatness  being  the  highest 
possible  in  the  scale.  Writers  who  desire  to  avoid  this  distinction  use 
instead  of  dullness  the  term  impaired  resonance,  modified  by  the 
adjectives  "slight,"'  "considerable."  and  "marked".  Their  incon- 
.sistenee  is  made  apparent  by  the  terms  "i-elative  dullness,"  "dullnes-s 


*6th   Edition.  Mi'dical  Diagnosis,  p.  240. 


PHrSIC^Uj    EXAMINATION  73 

more  marked",  etc.,  which  are  used  by  most  systemic  writers  on 
practice. 

A  protracted  discussion  of  the  theories  of  percussion  sounds  would 
be  profitless.  Two  only  have  received  extensive  recognition,  that  of 
Gee,  who  believes  that  the  vibrations  originate  in  the  bronchi,  and 
that  of  Bristow,  who  advocates  that  the  tones  are  produced  solely  by 
vibrations  of  the  chest  walls,  hence,  any  interference  with  these  vibra- 
tions changes  the  note. 

Scale  of  Pitch.  Arranging  the  notes  on  a  descending  scale,  be- 
ginning with  the  apex  note,  or  note  of  theoretically  highest  pitch,, 
we  have : 

Flatness 

Dullness 

Osteal 

Tubular 

Vesicular 

Vesiculo-tympanitic 

Small  tympany 

Large  tympany 

It  may  assist  the  student  somewhat  in  his  conception  if  we  com- 
pare these  eight  variations  with  the  notes  in  the  musical  scale  from 
high  C  to  low  C,  with  this  reservation,  that  the  resemblance  ends  with 
the  fact  that  each  of  the  percussion  notes  is  lower  than  its  predecessor. 

While  the  above  subdivision  of  the  percussion  notes  might  seem 
at  first  glance  to  be  an  unnecessary  refinement,  the  terms  are  all  met 
with  in  the  works  of  various  standard  writers,  hence  a  clear  classi- 
fication of  them  for  the  benefit  of  the  student  cannot  be  amiss. 

It  is  to  be  prefaced  that  the  percussion  sounds  produced  over  the- 
pulmonary  areas  can  vary  in  health  only  in  regard  to  pitch,  intensity 
and  duration.  Pitch  changes  with  the  number  of  vibrations  per  sec- 
ond, the  greater  the  number  of  vibrations  the  higher  the  pitch ;  while 
the  intensity  varies  with  the  amplitude  of  the  vibrations,  the  law 
being,  the  greater  the  amplitude  the  louder  the  sound.  Duration- 
varies  inversely  with  pitch,  the  higher  the  pitch  the  shorter  the  dura- 
tion of  the  sound.  The  pitch  also  varies  with  the  degree  of  tension,, 
both  of  the  covering  of  the  lungs  and  of  the  organ  itself.  The  rule 
above  given  applying  again,  viz.,  the  greater  the  tension  the  higher 
the  pitch,  just  as  in  musical  instruments,  the  tighter  the  string  is. 


74  I'llVSlC'AI.    EXAMINATION 

tuned  up  the  hi^rher  the  note.  The  jiitch  of  the  piihiionary  percussion 
sounds  is  altered  by  disease  either  in  llir  dinction  of  diillness  or  of 
tympany.  Changes  in  the  sounds  are  l)est  appreeiated  by  eareful  com- 
parison between  coi-i'espondinii  areas  of  the  two  lunji:  sui'faees,  ifrnorinp 
for  the  moment  the  very  slijzht  differences  wliich  normally  e.xist. 

CIIA.XOES   IX  THE   PT'LMOXARY   I'ERCl'SSIOX  XOTE   PKO- 

DfCEl)  P,Y  .MOKHIl)  PROCESSES. 

Increased  resonance  is  frei|Uently  met  with.  If  is  called  hyper- 
resonance.  Its  quality  is  that  of  the  noriiiMl  pm-ussion  imic  inure  or 
less  exaggerated,  that  is  to  say.  the  ruhniii  of  sound,  tlir  inh-nsity 
and  duration  are  increased,  while  its  |)itch  is  lowered.  I(  ineMiis  in- 
creased volume  in  the  air  vesicles  without  increase  in  the  tension.  Tem- 
porary over-distension  produces  this  note  in  its  slightest  degree,  while 
emphysema  produces  a  more  marked  example. 

Skoda 's  resonance  is  a  note  of  higher  piti'li  than  true  lympany. 

yet  with  a  tympanitic  quality.     It  occurs  in  connection  with  tw n- 

ditions,  pleuritic  effusion  and  pneumonia  of  the  lower  loli-.  li  is 
most  .strikingly  manifest  in  the  infra-clavicular  region  in  a  case  of 
moderate  effusion.  Osier  says,  "In  the  subclavicular  region  the  atten- 
tion often  is  aroused  at  once  by  a  tympanitic  note,  the  so-called  Skoda 's 
resonance,  which  is  heard  perhaps  more  commonly  in  this  situation 
with  pleural  effusion  than  in  any  other  condition.  It  shades  insensibly 
into  a  fiat  note  in  the  lower  mammary  and  axillary  regions.  Skoda  "s 
resonance  may  be  obtained  also  behind,  .just  above  the  limit  of  effu- 
sion." Ty.son  maintains  that  Skoda 's  rescmance  and  Flint's  vesiculo- 
tympanitic note  are  identical. 

TynipaiiHic  Rcsonaiicr.  Lctwer  in  pitch  than  the  preceding  and 
produced  by  percussion  over  a  ciuantity  of  air,  "enclosed  in  walls 
which  are  yielding,  but  neither  tense  nor  very  thick."  (Da  Costa.) 
The  .sound  is  somewhat  musical,  and  the  pitch  varies  with  the  size  of 
the  cavity.  It  is  abnormally  present  in  pneumo-thoi'ax,  or  over  large 
pulmonary  cavities. 

Diminished  Resonance.  Inipdired  fesananee.  which  in  our  .scale 
we  have  denominated  dullness,  is  a  note  of  higher  pitch  than  the  nor- 
mal vesicular  sound,  but  the  diivation  of  the  note  is  shortei-  and 
sharper.  The  note  closely  resembles  that  produced  by  percussion  over 
a  thin  board:  hence  its  quality  is  described  as  wooden.  It  is  noticeable 
in    partially   consolidated   hing,    in   compression   or   disi)lacement   by 


PLATE  III. 
RELATIVE  AND  ABSOLUTE  PERCUSSION  AREAS. 

The  shaded  area  represents  the  area  of  flatness  of  heart  and  liver, 
fusing  into  one. 

The  dotted  area  marks  out  the  area  of  heart  and  liver  dullness 
obtained  by  deep  percussion. 

The  lower  dotted  line  represents  the  descent  of  the  liver  with  forced 
inspiration. 

T.  Traube's  tympanitic  or  semi-lunar  space. 


PHYSICAL    EXAMINATION  75 

morbid  growths.  Increased  resistance  generally  accompanies  it.  Even 
over  wholly  consolidated  lung  the  note  is  not  entirely  flat  so  long  as 
any  vesicular  substance  remains. 

Flatness  is  the  absence  of  tone,  absence  of  resonance,  and  is  the 
height  of  pitch.  Such  a  sound  is  heard  when  percussion  is  made  over 
the  thigh  or  over  a  large  pleuritic  effusion. 

Amplwric  resonance  is  metallic  in  quality,  while  tympanitic  in 
pitch.  It  indicates  a  large  hollow  space  with  firm  elastic  walls,  as  a 
•cavity  which  communicates  with  the  bronchus.  Percussion  over  the 
l,rachea  with  the  patient's  mouth  partly  open  furnishes  a  fair  imita- 
tion of  the  amphoric  quality. 

Till'  Cracked-Pot  Sound.  Bruit-de-pot-fele  of  the  French  writers. 
Its  quality  is  indicated  by  the  name.  This  sound  is  closely  associated 
with  amphoric  resonance.  The  condition  usually  occasioning  this 
sound  is  a  cavity  freely  communicating  with  the  bronchus,  the  cavity 
having  yielding  walls.  To  produce  the  sound  it  is  necessary  to  strike 
a  strong,  sharp  percussion  blow  while  the  patient  holds  the  mouth 
open.  It  may  be  imitated  by  striking  the  loosely  folded  hands  across 
the  knee.  Da  Costa  says  the  sound  is  met  with  independent  of  exca- 
vations in  ' '  pleurisy  above  the  seat  of  the  effusion ;  in  bronchitis  of 
children:  near  a  pericardial  exudation;  in  emphysema  and  certain 
instances  of  pneumothorax.  Indeed,  any  disorder  in  which  the  chest 
wall  remains  very  yielding,  and  in  which  a  certain  amount  of  air 
contained  in  the  lung  or  pleura  and  in  uninterrupted  connection  with 
the  extei-nal  air  is,  by  sudden  percussion,  forced  into  a  bronchial  tube, 
will  occasion  this  cracked-metal  sound. ' ' 

We  briefly  indicate  again  the  outlines  of  the  lungs,  (see  also 
isection  on  Divisions  of  the  Chest).  On  the  back  the  lungs  extend  from 
the  seventh  cervical  vertebra  (vertebra  prominens)  to  the  level  of  the 
bottom  of  the  tenth  dorsal.  In  front  the  apices  extend  for  varying 
distances  above  the  clavicle,  from  a  half  inch  to. one  and  a  half  inches 
in  extreme  cases.  On  the  right  side  we  encounter  hepatic  dullness 
about  one  and  a  half  inches  below  the  nipple.  On  the  left  side  cardiac 
dullness  begins  at  the  lower  border  of  the  third  rib.  In  the  left 
lateral  region  we  encounter  stomach  tympany  and  a  little  in  front  of 
the  mid-axillary  line  splenic  dullness  begins  at  the  ninth  rib.  An- 
teriorly, along  the  right  side  of  the  sternum,  the  right  lung  extends  as 
low  as  the  sixth  costo-sternal  cartilage.  The  left  overlaps  the  heart  as 
far  as  the  fourth  cartilage.    In  the  mid-axillary  line  the  edge  of  the 


7()  I-IIVSICAI.     KXAMiXATldX 

lunir  reaches  Ihe  lowei'  Ijordei-  of  the  seventh  liii.  'I'hc  liver  ilulliiess- 
is  therefore  indicated  by  a  line  be^'innin<r  at  tiie  .jiinclidii  of  thi-  fifth 
cartilage  witli  the  right  side  of  the  stenuiiii,  and  passing  over  the 
seventh  ril)  in  niiil-axilla,  the  lower  liody  of  the  tenth  posteriorly 
to  the  eleventh  vertebra.  It  should  be  remembered  that  in  the  erect 
position  the  spine  of  the  tenth  vertebra  is  on  a  level  with  the  middle 
of  the  body  of  the  eleventh.  The  bifurcation  of  the  trachea  is  behind 
the  sternum,  opposite  the  second  costosternal  cartilage  and  the  arch 
of  the  aorta  curves  from  ris^ht  to  Ii'ft  and  from  before  backwards 
over  this  division. 

AUSCULTATION. 

Auscultation  is  the  recognition  by  the  ear  and  the  delerminatiou 
of  the  significance  of  sounds  emanating  from  normal  or  diseased  struc- 
tures. It  is,  therefore,  almost  necessarily  limited  to  the  respiratory 
and  circulatory  systems.  The  late  Professor  Flint  picturestpiely  de- 
scribed it  as  a  kind  of  eaves-dropping. 

Auscultation  may  be  mediate,  by  means  of  the  stethoseojie,  or 
immediate,  by  the  direct  application  of  the  ear.  In  practice,  auscul- 
tation should  follow  percussion.  In  using  the  instrument  care  should 
be  taken  to  avoid  pressing  the  bell  too  firmly  against  the  tissues  as. 
false  sounds,  resembling  friction  sounds,  thus  may  be  easily  produced. 
In  the  case  of  children  the  premature  exhibition  of  the  stethoscope 
may  cause  fright,  and,  as  sounds  of  all  kinds  are  readily  transmitted 
through  the  thin  chest  walls  of  the  young,  often  its  use  may  be  dis- 
pensed with.  In  the  examination  of  the  lungs  the  stethoscope  is 
sometimes  of  doubtful  advantage  as  compared  with  immediate  auscul- 
tation, and  as  the  practitioner  fre(iuently  may  be  caught  minus  this 
poi'tion  of  his  armamentarium,  it  is  wise  to  practise  both  forms  of 
auscultation.  One  sometimes  encounters  cases,  especially  in  hos])ital 
and  dispensary  routine,  in  which  he  is  loath  to  apply  the  ear.  even 
with  towel  or  napkin  intervening,  and  occasionally  over-modest  female 
clients  make  objection  to  the  procedure.  It  is  to  be  observed  that  in 
the  case  of  females  the  configuration  of  the  breasts  renders  immediate 
auscultation  more  difficult  and  les.s  accurate  than  mediate:  likewise  in 
the  examination  of  the  heart  in  both  males  and  females,  by  reason  of 
the  circumscribed  area.';  of  the  valvular  sounds,  the  stethoscope  is 
almost  a  necessity  not  only  for  their  accurate  location  and  differen- 
tiation but  also  that  sounds  emanating  from  neighborine   organs,  as- 


PHYSIC.VL    EXAMINATION  77 

the  limgs  and  pleura,  may  be  excluded  more  readily.  If  it  is  desirable 
to  cover  the  chest  during  the  examination,  see  that  the  covering  be  of 
such  nature  as  not  to  interfere  with  the  transmission  of  sound  nor  of 
.  a  material  of  itself  to  originate  sounds.  The  best  covering  for  the 
purpose  is  a  thin,  gauze  undervest:  in  the  absence  of  which,  a  thin, 
soft  towel  is  a  fair  substitute.  Starched  garments  are  especially  to 
be  avoided.  The  author  has  known  the  soft  creaking  of  a  starched 
chemise,  freshly  donned  in  anticipation  of  the  examination,  to  be  mis- 
taken for  the  friction  sound  of  beginning  pleurisy. 

The  most  reliable  evidence  is  gathered  by  repeated  exammations 
•of  corresponding  areas,  causing  the  patient  alternate^  to  breathe  nat- 
urallj%  deeply,  to  cough  and  to  count,  as  occasion  requires.  I  have 
found  that  repeating  the  number  "nine  hundred  and  ninety  nine," 
ty  reason  of  its  ringing  character,  to  be  especially  suitable  in  testing 
vocal  and  tactile  fremitus. 

NORMAL  AXD  ALTERED  RESPIRATORY  SOUNDS. 

It  is  manifestly  impossible  to  recognize  alterations  in  the  pulmonic 
or  cardiac  sounds  unless  we  are  thoroughly  familiar  with  the  normal 
ones.  Conistant  .study  of  healthy  respiratory  and  heart  sounds  is  the 
only  way  in  which  the  ear  can  be  kept  in  accord  with  the  demands 
made  upon  it.  Just  as  the  musician  attunes  his  instrument  before 
playing,  so  the  diagnostician  should  constantly  attune  his  ear. 

The  varieties  of  respiratoi-y  sounds  which  are  recognized  in  health 
are  of  three  types,  but  the  unfortunate  lack  of  uniformity  in  nomen- 
clature is  not  only  most  confusing,  but  would  lead  the  student  to  con- 
clude that  there  are  half  a  dozen  varieties. 

It  must  be  emphasized  that  the  sounds  about  to  be  described  are 
natural,  and  only  have  a  pathologic  significance  when  heard  outside 
of  their  own  proper  spheres,  or  when  one  which  should  be  heard  in 
a  certain  locality  is  replaced  by  another. 

As  a  starting  point,  we  begin  with  the  air  sounds  heard  over  the 
glottis  or  larynx.  Here  the  ear  recognizes  a  harsh,  blowing  sound  of 
high  pitch  and  great  intensity,  heard  both  on  inspiration  and  expira- 
tion, which  acts  are  separated  from  each  other  by  a  distinct  silent 
interval.  The  quality  of  this  sound  is  unmistakably  blowing,  tubular, 
and  somewhat  hollow.  As  we  descend  from  the  larjoix  to  the  top  of 
the  sternum,  the  sound  undergoes  a  very  slignt  modification.  This 
sound  is  known  as  tracheal,  bronchial,  or  tnii'.i  tr  breathing;  the  vari- 


78  IMl^-SICAI.     KX  AMlNATIlIN 

Oils  'vriiis  hi'iii.u-  iisoi,!  by  elinVrciil  :iiithiirs  .-is  li:i\inu'  I  lie  saiiii-  siuniti- 
canee  and  beintr  interchanpeabk'. 

If  next  \vp  apply  the  instruiiu'iit  ovtT  \bv  sfcoiid  inlcisparc.  an- 
teriorly, we  hear  a  much  softer  sound.  Its  pitch  is  decidedly  Kiwcr, 
the  blowing  character  has  been  replaced  by  a  tientlc  breezy  iiislbni; 
of  short  duration,  heard  best  with  inspiration,  followed  ii-ilhnul  (uni 
appyrriiiblr  interval  by  a  still  softer  rxpiratorij  murnuir  uf  yel  lower 
pitch,  shorter  duration,  but  with  a  faint  sugfrestion  of  blowiui;-.  As  this 
Muii'nuir  is  supposed  to  ori^iinate  in  the  alveoli,  it  is  called  I'l siciiUir 
hrcafhing.  It  is  best  heard  as  well  as  most  i-harai-lcrislic  at  the  point 
indicated.  At  the  apices  and  low  down  posteiiorly  its  intensit.\-  dimin- 
ishes, but  its  quality  remains  unaltered.  This  is  what  is  meant  b,\-  tin- 
normal  breath  sound,  or  the  normal  respiratory  nnirninr.  and  llii- 
student  will  do  well  to  fix  indelibly  in  his  mind  its  (pialitirs. 

The  third  recognizable  type  falls  between  the  two  Jnst  di'scribi-d, 
and  shares  the  qiialities  of  each.  It  is  a  sonnd  heard  uvn-  tlir  snbdi- 
visions  of  the  trachea,  that  is  to  say  the  roots  of  the  lunus:  hence  is 
heard  normally  over  the  manubrium  in  front  and  in  the  interseapidar 
region  behind  as  far  down  as  the  top  of  the  fifth  dorsal  vertebra. 
With  inspiration  the  vesicular  element  is  diminished  but  not  absent. 
Inspiration  is  separated  from  expiration  by  a  distinct  interval,  shorter 
than  in  the  first  variety.  Pitch  and  intensity  likewise  fall  between 
the  two  varieties  above  described.  This  foi-ni  of  i-espii-dion  is  known 
as  broncho-vesicular  breathing. 

GIIAXGES    IX    THE    BREATIIIXG    SOl'XDS    PRODrcKI)    BY 
DISEASE. 

I.  The  vesiculai-  nnu'nnir  may  be  altered  in  intensit.v.  by  being 
increased  or  diminished,  or  the  murmur  may  be  suppressed. 

Increase  in  the  intensity  of  the  vesicular  murmur  is  called  pnrrilc 
breathing,  on  account  of  its  likeness  to  the  breath  sounds  noiiiially 
heard  in  children.  It  denotes  increased  activity  and  follows  violent 
exercise.  It  is  not  necessarily  a  sign  of  disease.  Inspiration  and 
expiration  are  equally  affected.  When  heard  in  adults  it  indicates 
that  an  increase  of  function  in  the  unaffected  portion  of  the  limgs 
is  compensating  for  diminished  activity  elsewhere.  It  is  often  called 
sunptemental  breathing  or  csaggrratcd  breathing.  One  of  the  best 
examples  of  its  occurrence  in  disease  is  the  respiratory  murmur  heard 
over  the  sound  side  in  eases  of  pleuritic  effusion. 


PHYSICAL    KSL:\.MINATION  79' 

II.  Diminished  Breathing.  Diminished  or  feeble  respiration  is 
the  opposite  condition  to  puerile  breathing-.  It  is  due  to  diminished 
functional  activity,  caused  by  obstruction  to  the  entrance  of  air  into 
the  vesicles ;  by  partial  obliteration  of  the  cells  by  deposits  within,  or 
from  pressure  upon  them.  The  character  of  the  normal  breath  sounds 
is  unaltered,  but  the  intensitv'  is  diminished.  It  may  arise  in  the 
course  of  a  variety  of  affections,  as  paralysis  or  pleurodynia.  Feeble 
respiration  at  the  apex  combined  with  impaired  percussion  resonance 
is  a  strong  indication  of  the  early  stage  of  tuberculosis. 

III.  Absence  of  the  Respiratory  Murmur.  Large  pleural  effu- 
sions, massive  pneumonia  in  which  the  secretion  totally  occludes  the 
bronchi,  and  collapse  of  the  lung,  are  the  only  conditions  likely  to 
caiise  entire  absence  of  the  breath  sounds. 

IV.  The  respiratory  rhythm  may  be  so  changed  that  the  relative 
length  of  inspiration  to  expiration  is  altered ;  or  the  respirations  may 
become  uneven  and  jerky,  exhibiting  the  so-called  wave  or  cog-wheel 
character.  In  the  first  instance  it  is  the  expiration  which  is  most 
affected  and  the  change  is  usually  in  the  nature  of  a  prolongation  of 
that  act.  The  prolongation  is  generally  accompanied  by  a  change  of 
pitch.  If  the  pitch  be  elevated  it  means  consolidation,  deposits  within 
the  air  cells  or  in  the  nearbj^  bronchi.  Here  the  quality  of  the  sound 
gradually  ascends  to  bronchial  or  tubular.  If  the  pitch  is  low  and 
the  quality  unchanged,  it  indicates  emphysema.  In  the  one  ease  the 
bronchial  deposits  mechanically  dam  back  the  air:  in  the  other  the 
loss  of  elasticity  causes  the  expiratory  prolongation. 

Cogwheel  Respiration.  The  inspiration  is  disconnected,  broken 
into  two  or  three  parts  due  to  the  une^'en  expansion.  Affections  of 
the  muscles  of  respiration  or  previous  disease  of  the  lungs  or  pleura, 
especially  old  adhesions,  or  diseases  of  the  bronchi  offering  an  impedi- 
ment to  the  entrance  of  air  are  the  causes.  It  has  been  met  with  in 
hysteria,  in  intercostal  neuralgia  and  other  spasmodic  affections,  as 
well  as  in  pulmonary  tubercular  deposits  of  which  it  was  once  con- 
sidered a  pathognomonic  sign.  Here  its  favorite  seat  is  near  the 
apices. 

Bronchial  Breathing.  The  character  of  this  respiration  has  been 
already  described.  "When  heard  over  the  vesicular  areas  of  the  lungs 
as  the  result  of  disease  the  qualities  above  attributed  to  it  are  little 
altered  but  the  intensity  is  diminished.  The  tracheal  sound  as  heard 
at  the  root  of  the  neck  posteriorly  is  the  prototype  of  bronchial  respira- 


80  PHYSICAL    EXAMINATION 

tion  and  should  be  used  as  the  standard  of  eomparisou.  Broncliijil 
hreathiuy:  is  higher  in  pitch  than  the  vesicular  inspiratory  sound  and 
retains  more  of  its  tracheal  qualities.  Its  expiratory  quality  is  af- 
fected in  the  same  way,  its  intensity  increased,  its  duration  equal  to  or 
longer  than  inspiration,  its  pitch  elevated,  and  inspiration  and  expira- 
tion separated  by  a  distinct  interval.  Bronchial  breathing  signifies 
the  consolidation  of  the  vesicular  structure  from  deposits  within,  or 
air-cell  obliteration  from  pressure  from  without.  The  sounds  of  the 
still  patent,  large-caliber  bronchi  are  then  conducted  through  the 
denser  tissue  to  the  ear,  replacing  the  vesicular  nnirnuii'  and  causing 
it  to  appear  as  though  the  souuds  originated  immediately  under 
the  ear. 

Sometimes  adventitious  growths,  as  solid  tuinois  or  aneurysms, 
intervening  between  the  chest  wall  and  the  trachea  or  a  large  bronchus, 
will  cause  obliteration  of  the  air  cells  and  the  bronchial  bruit  is  then 
heard  over  the  tumor  area. 

As  indicating  consolidation,  bronchial  breathing  is  heai'd  in  pneu- 
monia and  in  the  infiltrated  areas  of  phthisis.  As  the  result  of  intra- 
thoracic pressure  it  is  heard  over  the  compressed  lung  above  moderate 
and  large  effusions. 

Broncho-vesicular  Breathing.  When  heard  peripherally  in  dis- 
eased conditions  it  portends  partial  consolidation,  but  le.ss  in  degree 
than  that  indicated  by  bronchial  respiration.  It  is  subject  to  varia- 
tions in  quality,  especially  intensity,  and  may  pass  into  the  bronchial 
type  by  exacerbation  of  the  conditions  which  cause  it.  As  the  change 
■occurs,  more  and  more  of  the  vesicular  element  is  lost  and  the  tracheal 
quality  assumed,  as  indicated  by  an  ascent  of  both  intensity  and  pitch. 
Tubular  Breathing,  as  the  term  is  generally  used,  is  synonymous 
with  bronchial  breathing.  It  indicates  the  breathing  of  complete  con- 
solidation, as  does  the  latter,  but  the  former  term  is  more  limited  in 
its  application.  Its  quality  is  described  as  whiffling,  and  its  pitch  as 
higher  than  the  bronchial  pitch.  Like  the  latter  tubular  breathing  is 
present  in  pneumonic  consolidation  and  in  the  complete  consolidations 
sometimes  met  with  in  the  superficial  areas  of  phthisis. 

Cavernous  Breathing,  as  its  name  indicates,  is  produced  by  the 
entrance  and  exit  of  air  from  a  cavity.  The  cavity  may  be  within  the 
lung  substance  or  external  to  it,  without  causing  alteration  of  the  cav- 
•ernous  sound,  provided  it  be  entirely  or  partially  empty  and  that  it 


PHYSICAL    EXAMINATION  81 

•communicates  with  an  open  bronchus.  It  is  asserted  that  a  cavity  must 
be  as  large  as  a  walnut  to  produce  the  phenomena  attributed  to  it. 

The  inspiration  is  low-pitched.  IioUow  and  blowing,  as  is  the  ex- 
piratory sound.  Often,  but  not  invariably,  expiration  is  still  lower  in 
pitch  than  inspiration,  which  is  the  reverse  of  bronchial  breathing. 
The  pitch  is  never  raised  on  expiration  and  expiration  is  longer  than 
inspiration.  It  reciuires  for  its  production  yielding  walls.  As  a  stand- 
ard of  comparison  for  cavernous  breathing,  we  compare  it  with  the 
sound  heard  at  the  lower  end  of  the  trachea.  The  sound  is  often  asso- 
ciated with  gurgling,  due  to  fluids  confined  in  the  vomicit,  which  may 
disappear  when  the  cavity  is  entirely  filled,  to  reappear  after  expec- 
toration. It  is  significant  of  the  third  stage  of  phthisis,  of  bron- 
chiectasis or  of  pulmonary  abscess. 

Amphoric  Breathing,  like  cavernous,  require,s  a  cavity  with  resil- 
ient walls  communicating  with  a  bronchus.  It  is  a  high-pitched,  blow- 
ing sound,  the  qualities  being  those  of  cavernous  breathing  in  an  exag- 
gerated degree.  But  in  addition  thereto  it  has  an  echoing,  metallic 
character,  as  has  the  corresponding  percussion  note.  It  may  be  imi- 
tated by  blowing  across  the  mouth  of  a  bottle  or  jug  (Amphora).  Its 
intensity  varies.  It  indicates  a  lai-ge  cavity  and  usually  means  pneu- 
mothorax. Rarely  a  pulmonary  cavity  may  afford  the  necessary  con- 
ditions for  its  production. 

NEW  OR  ADVENTITIOUS  SOUNDS. 

In  addition  to  the  changes  and  modifications  of  the  respiratory 
rhythm  already  described,  auscultation  reveals  certain  sounds  which 
are  in  no  wise  related  to  or  analogous  to  the  normal  sounds.  Such  are 
rales,  rhonchi,  friction  sounds,  echoes  and  the  like. 

Bales  are  peculiar  sounds  generated  in  the  air  tubes  by  the  pass- 
age of  air  through  exudates  contained  therein,  or  by  the  forcible  sep- 
aration of  agglutinated  surfaces,  as  the  swollen  lining  of  the  small 
bronchi  or  the  collapsed  alveoli.  When  they  originate  in  a  portion  of 
the  lung  which  has  undergone  consolidation,  or  when  due  to  the  forma- 
tion of  a  thick,  viscid  and  not  easily  displaced  exudate  into  the  cells, 
the  character  of  the  sound  is  sharp,  crackling,  dry,  or  even  explosive. 
These  sounds  are  described  as  crepitant  or  crackling  rales,  and  are 
gauged  according  to  size  and  intensity  into  small,  medium  and  large 
crepitant  rales.  As  already  .stated,  they  mean  consolidation  of  the 
Tresicular  portions  of  the  lungs.    The  small,  sharp  crackle,  heard  often- 


82  I'HYSICAI-    EXAJIIXATION 

est  willi  inspiratioi!.  (iriiiiiiates  in  the  alveoli,  and  is  heai'il  in  the  early 
stages  of  tubereiilar  foi-niatiou,  or  may  be  accepted  as  the  earliest  sign 
of  the  softening  stage  of  the  pueuniouic  process.  This  rale  is  not 
limited  to  inspiration,  bnt  may  also  be  heard  dnring  expiration.  The 
larger  crackling  raies  are  in  character  the  same  as  the  small  riiles 
and  indicate  an  extension  of  the  associated  processes.  Hence  they  are 
heard  in  the  softening  stage  of  pneumonia  and  of  tubercular  deposits. 
They  also  occur  in  broncho-pneumonia.  The  largest  crepitant  rales 
are  confined  almost  entirely  to  minute  cavities,  surrounded  by  areas 
of  consolidation  which  form  during  tubercular  softening. 

Sounds  produced  in  the  maimer  just  described,  particularly  when 
they  emanate  from  lungs  whose  structure  is  little  altered,  and  in  which 
the  lesions  are  confined  principally  to  the  lining  membrane  of  the 
tubes,  vary  in  character  with  the  anioiuit  and  nature  of  the  secretion. 
They  may  originate  in  any  portion  of  the  bronchial  tract,  including 
the  trachea,  but  usually  are  confined  to  the  lesser  bronchi.  When 
these  sounds  are  dry  and  have  somewhat  of  a  musical  character,  they 
are  termed  rhonchi.  When  their  natm-e  indicates  the  presence  of 
liquid  in  the  tubes,  they  are  denominated  moist,  liquid,  or  mucous 
rales.  Sometimes  the  sounds  suggest  the  breaking  of  small  bubbles. 
Sixth  sounds  originate  in  the  smallest  bronchioles  and  are  heard  in 
capillary  bronchitis.    Others  are  larger  and  have  a  gurgling  character. 

All  of  these  sounds  are  extremely  evanescent,  changing  their  loca- 
tion, appearing  or  disappearing  with  forced  respiration,  coughing,  or 
change  in  the  position  of  the  patient.  They  may  be  so  turbulent 
as  to  entirely  obscure  the  normal  respiratory  murmur.  These  rales 
are  named  small,  medium  and  large  bubbling  or  mucous  rales,  and 
the  names  are  sufficiently  descriptive  of  their  location  and  character. 
The  large  rales  occur  in  cases  invohing  the  trachea  or  largest  bronchi, 
and  are  eonnnon  in  chronic  conditions,  such  as  tracheitis  and  bron- 
chitis. They  are  the  cause  of  the  "death  rattle"  sometimes  heard  in 
expiring  persons.  These  rales  are  heard  in  all  pulmonary  diseases  in 
which  inrtammation  of  the  bronchi  is  the  essential  element  of  the  dis- 
ease or  occurs  as  a  complication.  I'ure,  large  gurgling  rales,  having 
the  character  of  liquid  poured  from  a  bottle,  are  confined  to  partially 
filled  cavities,  and  are  heard  on  coughing. 

fi'honchi  are  dry  sounds,  and  like  wet  rales  are  confined  to  the 
bronchi.  They  vary  in  both  character  and  pitch  according  to  their 
location  and  the  amount  of  obstruction  or  narrowinir  produced  by  the 


PHYSICAL    EXAMINATION  83 

causative  condition.  The  narrower  the  tu?je,  the  higher  the  pitch  of 
the  sound.  Such  narrowing  may  result  from  swelling  of  the  membrane, 
as  is  apt  to  be  the  case  in  infianmiations  of  the  finer  diAdsions,  or  from 
secretions,  which  Is  the  usual  cause  of  their  occurrence  in  the  large 
tubes ;  or  the  two  causes  may  operate  together,  as  in  bronchitic  asthma. 
The  low-pitched  rhonchi  are  called  soiioroKS,  owing  to  their  reverber- 
ating character;  the  high-pitched  are  called  sibilant  by  i-eason  of  their 
hissing-  nature.    Others  have  a  whistling  sound. 

They  may  be  heard  on  either  inspiration  or  expiration,  or  both, 
and  accompany  acute  and  chronic  inflammations  of  the  bronchi.  The 
finer,  higher-pitched  rhonchi  are  heard  in  acute  conditions  and  when 
exacerbations  or  extensions  of  chronic  forms  take  place.  They  are 
very  variable  and  large  rhonchi  may  suddenly  disappear.  The  finer 
varieties,  indicating  obstruction,  are  somewhat  more  stable.  As  has 
been  said  under  Cough,  they  often  indicate  the  first  stage  of  a  condi- 
tion in  which  moist  rales  are  the  second  stage.  Bronchitis  and  asthma 
and  emphysema  give  us  the  best  examples. 

Stridor  is  the  name  given  to  the  harsh,  rough,  vibrating  sound 
imparted  to  the  breathing  by  certain  conditions.  It  might  be  called 
respiratory  tremor.  The  breathing  is  noisy  and  labored,  inspiration 
is  prolonged  and  the  voice  is  often  raucous.  Direct  pressure  on  the 
larynx,  trachea  or  a  large  bronchus  produces  it,  hence  the  most  fre- 
quent cause  is  thoracic  aneurysm  or  a  mediastinal  growth.  Next  in 
frequency  is  syphilitic  stenosis.  If  due  to  local  conditions  as  inter- 
laryngeal  growth  or  paralysis  of  the  vocal  cords,  an  examination  of 
the  larynx  will  reveal  the  cause. 

Friction  Sotinds.  These  sounds  result  from  the  rubbing  together 
of  two  inflamed  pleural  or  pericardial  surfaces.  In  older  cases  the 
surfaces  are  roughened  from  the  deposit  of  exudate,  or  fine  fibrous 
union  maj'  have  formed. 

Friction  sounds  consist  of  a  number  of  short,  repeated  sounds  of 
a  crackling,  rubbing  or  crepitant  nature.  They  are  often  compared 
with  the  creaking  of  new  leather.  They  are  usually  heard  over  a  very 
limited  area,  possibly  never  exceeding  in  size  a  half  dollar.  They  are 
unilateral  and  oftenest  confined  to  the  lower  thoracic  areas. 

Pleural  friction  sounds  are  generally  heard  on  both  inspiration 
and  expiration,  but  may  appear  only  at  the  end  of  forced  inspiration. 
The  sounds  are  frequently  referred  to  as  "come  and  go"  sounds.    It  is 


iS4  I'ilVSICAI.     KXAMINATION 

oftoii  liitluMilt   til  decide  wlictlii'i-  the  somiil  arises  from  idteiatiun  of 

the  pericardial  sac  or  of  the  pleural  niembiane. 

The  following'  points  will  aid  in  the  distinction: — 

Till'    location:    the   evident    supeificial    situjitinn    of    the    plein-al 

soiltids. 

The  relation  of  the  two  sounds  to  respiration  above  mentioned : 

pericardial  sounds  do  not  disappear  when  respiration  is  suspendetl. 
From  the  crepitant  rale  it  is  distinguished  by  the  fact  that  pleural 

st)unds  are  influenced  by  neither  coufih  nor  by  respiration. 

That  deep  respiration  increases  the  pain  in  the  case  of  friction. 
That  friction  areas  are  nioi'e  circumscribed  and  that   the  i-ale  is 

lieai'd  only  on  inspiration. 

AUSCULTATION  OF  THE  VOICE  SOUNDS. 

When  the  ear  is  applied  to  the  normal  chest  while  the  patient 
speaks  a  di.stant.  muffled,  humming,  vibratory  sound  is  heard.  Th.' 
spoken  woids  are  inarticulate.  The  sound  is  stronjrest  in  deep-chesletl 
adult  males  and  weakens  by  srradations  in  women  and  children.  What- 
ever the  character  of  the  sound  may  be,  it  is  pretty  constant  in  pitch 
and  intensity  over  the  entire  pulmonary  periphery  of  the  individual. 
The  sound  is  called  normal  vocal  resonance.  It  is  more  intense  in 
the  vicinity  of  the  trachea  and  large  bronchi  and  is  slightly  more 
intense  in  the  right  infraclavicular  region  than  in  the  corresponding 
region  on  the  left.  Conditions  which  increase  conductivity  increase  the 
intensity  of  the  sound  and  vice  versa.  Hence  consolidation  of  the 
lung  of  any  degree  whatsoever  increases  it. 

The  pitch  is  unaltered  in  this  case  but  the  sounds  are  louder.  On 
the  other  hand  emphysema,  in  which  the  lung  is,  so  to  speak,  7-arefied. 
diminishes  the  vocal  resonance,  as  does  also  pnetunothora.x,  by  separ- 
ating the  conducting  substance  from  the  chest  wall.  Thickened  pleura 
similarly  affects  it  by  offering  a  barrier,  and  over  pleural  effusions  it 
is  totally  absent. 

Occlusion  of  the  bronchi  by  mediastinal  growths,  aneurysm  or 
other  causes,  prevents  the  sound  waves  from  reaching  the  periphery, 
hence  vocal  resonance  is  also  absent  in  these  conditions. 

This  absence  will  be  understood  readily  when  it  is  considered  that 
the  vibrations  set  up  by  the  act  of  speaking  must  reach  the  surface  by 
traversing  the  intervening  air  column.  If  the  column  is  interrupted  by 
bi-onchial  obliteration,  the  sound  wa\es  will  he  absent  over  the  lung 


PHYSICAL    EXAMINATION  85 

surface  so  supplied  and  likewise  over  the  corresponding  area  of  lung 
covering. 

Bronchophony.  Over  the  large  bronchi  the  voice  sounds  heard 
in  health  are  of  greater  intensity,  more  sonorous,  more  concentrated 
and  of  higher  pitch  than  those  sounds  heard  over  the  vesicular  regions. 
This  is  called  the  bronchial  voice  and  is  the  type  of  bronchophony. 
The  sound  seems  to  be  near  the  ear.  The  term  bronchophony  means, 
therefore,  increased  or  augmented  vocal  resonance.  It  bears  the  same 
relation  to  normal  vocal  resonance  as  does  bronchial  breathing  to 
the  normal  vesicular  breath  sounds,  and  when  heard  in  localities  other 
than  over  the  roots  of  the  lungs  means  increased  conductivity,  hence 
consolidation.    The  sounds  are  inarticulate. 

Pectoriloquy  is  the  name  given  by  Laennec  to  the  distinct  trans- 
mission of  articulate  words  through  the  chest  to  the  ear.  By  some 
it  is  regarded  simply  as  exaggerated  bronchophony.  In  character  the 
sound  closely  resembles  the  sound  of  the  voice  heard  over  the  larynx. 
In  bronchophony,  as  stated,  the  sounds  are  inarticulate,  while  in  pec- 
toriloquy not  only  is  sound  of  like  Cjuality  transmitted  to  the  ear,  but 
the  articulate  words  are  audible.  In  a  few  cases  the  sounds  not  only 
seem  to  arise  under  the  ear,  but  are  much  intensified  and  the  pitch 
elevated.  This  is  a  union  of  bronchophony  and  pectoriloquy  and  is 
named  bronchophonic  pectoriloquy. 

In  other  instances  the  character  of  the  voice  sounds,  although 
articulate,  are  distant,  hollow  and  even  may  be  slightly  ringing.  Here 
the  pitch  is  not  elevated,  the  area  is  limited  and  the  words  do  not 
seem  to  arise  under  the  stethoscope.  This  Flint  named  cavernous  pec- 
toriloquy. He  says  that  the  former  means  solidification,  the  latter 
a  cavity. 

Amphoric  Voice  is  so  named  when  in  addition  to  being  ringing 
and  hollow  it  has  also  a  musical,  a  metallic  or  a  tinkling  character. 
The  sounds  are  not  articulate  as  in  pectoriloquy.  It  is  generally  taken 
to  mean  pneumo-hydrothorax,  but  may  occur  in  large  cavities  offering 
similar  conditions,  especially  large  vomica;  whose  walls  are  formed  bj^ 
limiting  membrane. 

Egophony  is  bleating  bronchophony,  caused  by  a  thin  layer  of 
fluid  set  into  vibration  by  the  voice.  It  is  of  very  rare  occurrence, 
but  has  been  found  in  cases  of  moderate  pleural  effusion,  its  usual  seat 
being  at  the  lower  angle  of  the  scapula. 

The,  Whispered  Voice  changes  or  is  modified  by  disease  as  well  as 


86  PHVSIC.VL,    EXAMINATION 

the  spoken  voici-.  Xormally  the  whisjiei'  resonance  is  not  heard  ex- 
cept over  the  large  bronchi  which  form  the  roots  of  the  lungs,  and 
the  adjacent  areas  in  the  upper  thorax.  Here  is  it  a  soft,  blowiuj: 
sound  which  accompanies  each  word.  Increased  or  exaggerated  whis- 
pend  resonance  and  whispering  brunchophony  may  be  said  to  be  pres- 
ent when  the  normal  whisper  .iust  described  is  heard  over  the  vesicular 
areas  of  the  chest,  where  they  are  uever  normally  present.  The  whis- 
pered sounds  then  have  the  characteristics  of  their  spoken  congeners. 
The  second  of  these  two  is  higher  in  pitch,  more  intense  and  nearer 
the  ear  than  the  first.     It  indicates  consolidation. 

Also  may  we  have  whispering  pectoriloquy,  aniphorie  whisper, 
and  cavernous  whisper.  Whispering  pectoriloquy  is  a  surer  indica- 
tion of  cavity  than  its  spoken  equivalent.  The  whispered  voice  is  some- 
times transmitted  in  pleurisy  when  the  spoken  voice  is  not.  Bacelli 
considers  this  sign  as  diagnostic  between  serous  and  purulent  ett'iisions. 
but  clinical  experience  does  not  l)ear  him  ciut.  It  is  however  perpet- 
uated as  Bacelli 's  sign. 

There  still  remain  to  be  considered  a  few  adventitious  soiinds  of 
somewhat  rarer  occurrence  than  those  already  described. 

Crepitaiion.  A  fiue,  crackling  sound  exactly  imitated  by  rubbing 
the  hair  between  the  fingers,  close  to  the  ear.  It  has  long  been  accepted 
as  the  earliest  sign  of  fibrinous  deposit  within  the  air  cells  in  pneu- 
monia. It  may  also  occur  when  air  enters  the  collapsed  air  vesicles 
and  is  due  to  the  separation  of  their  walls,  hence  is  heard  at  the  end 
of  inspiration  (see  Pneumonia).  It  may  be  present  also  in  hypostatic 
pneumonia,  (edema  of  the  lungs  or  in  areas  of  lobular  collapse. 

Succiission  Splash.  This  was  described  by  Hippocrates,  and  is  a 
pecnliar  splashing  sound  produced  by  violent  coughing  or  a  sudden 
shaking  of  the  body.  A  large  cavity  containing  both  air  and  fluid  is 
necessary  for  its  production.  It  may  be  exactly  imitated  by  splashing 
an  uncorked  earthenware  jug  containing  a  small  quantity  of  water.  It 
is  present  in  hydro-  or  pyo-pneumothoi-ax  (q.  v.). 

Coin  Ring  or  Bell  Sound  may  be  produced  in  pneumothorax  or 
in  ven-  large  pulmonary  cavities.  A  coin  is  placed  flat  against  the 
chest  and  is  struck  with  the  edge  of  another  coin :  with  the  stethoscope 
applied  over  the  affected  area,  is  heard  a  clear,  bell-like  tinkle. 

Metallic  Tinkling  is  a  sound  which  Loomis  likened  to  dropping 
pins  or  small  shot  into  a  metallic  vase.  The  sound  is  echo-like,  clear, 
high-pitched  and  ringing.    It  may  be  single  or  a  series  of  sounds,  may 


PHYSICAL    EXAMINATION  87 

be  produced  by  the  movements  of  respiration,  by  coughing  or  even  by 
speaking.  A  large,  dense-walled  pulmonary  or  pleural  cavity  and  a 
communicating  bronchus  are  necessary  for  its  production.  It  is  often- 
est  heard  in  pneumo-hydrothorax.  Dr.  Walsh  regards  it  as  due  to 
the  echo  of  bursting  bubbles  shut  up  in  the  cavity.  It  is  also  attrib- 
uted to  dripping  fluid  striking  upon  a  liquid  surface.     The  term  am- 


Fig.   2/ — Laryngeal    mirror   with   electrical    connections. 

phoric  echo  is  used  in  the  same  connection  to  describe  the  above  sound, 
or  one  very  similar. 

Post-tussive  Suction,  a  rare  but  valuable  sign  of  cavity.  When  an 
excavation  is  so  conditioned  as  to  be  compressed  by  the  act  of  cough- 
ing, the  air  is  expelled  therefrom  during  that  act  with  a  slight  hissing 
noise.  The  dilatation  of  the  cavity  after  compression  is  sometimes  fol- 
lowed by  an  "audible,  air-suction  sound,  varying  in  intensity  with  the 
size  of  the  ea^aty.  The  name  is  suffieientl.y  descriptive  of  its  quality. 
A  sound  similar  to  the  above,  also  produced  by  air  entering  a  cavity 


Fig.   28 — Laryngeal    Mirror. 

with  inspiration,  has  been  described  by  Laennec,  Skoda  and  others, 
and  called  "the  puff". 

THE  LARYNGOSCOPE. 

This  well-known  instrument  enables  us  to  view  the  interior  of  the 
larynx,  the  vocal  cords  and  a  portion  of  the  trachea. 

Acute  and  chronic  laryngitis  cause  hypersemia,  erosions  of  the 
cords  and  occasionally  a  slight  exudate.  In  the  chronic  form  the  mem- 
brane is  thickened.  QCdema  and  pseudo-membranous  formations  give 
names  to  their  respective  varieties. 

Tuberculous  Inflammation.  The  vocal  cords  a' c  i.ix"  er:<l  and 
eroded,  the  movements  restricted:  infiltration,  superficial  a-:d  deep,  is 


8S  PIIVSIC'AI.     KXAMINATIIIN 

seen.  Thickeniiii:  of  the  ar\  tciioids  is  tlie  i-arlicsl  si'.'ii.  Oilier  symp- 
toms of  tubereulosis  eoexist. 

Laryugeal  Stjpliili!<.  Syniiiu'trieal  siipcrlicial  ulcers  oi-i-ur  early. 
(Jumma.  deep  ulceration  and  necrosis  of  the  cartilat-es  are  tertiary. 

Paralysis  of  the  lanjncjcal  muscles  arises  from  various  central 
lesions,  medullary  syphilis,  multiple  sclerosis,  locoiiKitoi'  ataxia  and 
hysteria.  In  another  s'ronp  of  paralyses  the  lesion  atlfcts  thr  Hbres  of 
the  recurrent  laryni>:eal  in  their  tortuous  course,  or  the  laryngeal  fibres 
in  the  vatrus  or  accessory  nerve,  or  the  direct  larynfreal  nerve  is  subject 
to  ])ressui'e.     Xew-irrowths  are  the  principal  cause  of  such   paralysis. 


Fig.  29— Laryngeal  Hcadliglit. 

The  left  nerve  is  most  exposed  to  injtiry  owinti'  to  its  ccmrse  around  the 
aorta.     Mention  is  made  of  the  condition  under  Aneurysm. 

Causes.  Aneurysm,  pleural  thickeuino-.  mediastinal  tumors,  en- 
larged bronchial  srlands,  carcinoma  of  the  a^sophajjus,  enlarged  thyroid 
and  even  pericardial  effusions  are  assigned  as  peripheral  causes  of 
the  lesion. 

THE  OPHTHALMOSCOPE. 

The  examination  of  the  eye-ground  liy  means  of  this  instrument 
adds  greatly  to  our  diagnostic  knowledge.  Mr.ch  infoi-mation  is  within 
reach  of  the  general  observer  even  though  he  has  not  leceived  special 
training  in  technic. 

Besides  disea.ses  .strictly  pertaining  to  the  eye.  the  following  enn- 
ditions  are  worthy  of  attention. 

Choroiditis.  Syphilis,  rheumatism  and  gout  often  originate  the 
disease.  Typhoid  and  puerperal  fevers,  septicivmia  and  conditions 
causing  thrombosis  are  sometimes  complicated  by  it. 

Tubcrdf-    of   the   rhomiel    is   observabh^   in    miliai'y   tuberculosis; 


PHYSICAL    EXAMINATION 


89 


gunima  in  syphilis.  Sarcoma  of  the  choroid  is  met  with  occasionally, 
the  subjects  being  usually  above  thirty-five  years  of  age. 

Pulsation  of  the  retinal  veins  occurs  during  cardiac  diastole  but 
is  physiologic.  Pulsation  of  the  arteries  is  generally  pathologic.  It  is 
seen  in  states  of  increased  or  diminished  arterial  tension  and  occurs  in 
aortic  regurgitation  with  hypertrophy,  in  Basedow's  disease,  in  sjti- 
cope  after  ha;morrhage. 

Papillitis  is  most  frequently  caused  by  intracranial  disea.ses.  es- 
pecially cerebral  tumors  or  meningitis,  but  glycosuria,  albuminuria, 


Fig.  30 — Lar\'ngeal  Reflector. 


lead-poisoniug,  anaemia,  amenorrhcea  and  syphilis  also  are  recognized 
causes.  ... 

Atrophy  of  the  optic  nerve  occurs  in  spinal  diseases  as  tabes  dor- 
salis,  in  syphilis,  diabetes  and  malaria.  Toxic  agents,  alcohol,  tobacco 
and  lead  are  designated  as  cairsative. 

Cardiac  vahiilar  diseases  may  cause  embolism  of  the  retinal 
artery,  as  may  also  albuminuria  and  preg-nancy. 

Retinal  hcemorrhacje  may  result  from  numerous  derangements  of 
the  vascular  system,  as  arterial  sclerosis,  vahiilar  diseases,  especially 
mitral  disease,  embolism  and  thrombosis,  miliary  aneurysm  and  the 


90 


IMIVSU'AI,     K.\  AM  I  NATION 


rolliiwini:'  liCiH'i-Ml  c-oaditiiiiis:     DiMlu'lcs.  ;illiiiniiiiiiri:i.  pci'iiiciiiiis  aiiu'- 
iiiia.  piii-inira.  scurvy  aiul  h'nk  i  iiiia. 

li'iliiillis   is  caused  bv  alhuniitiuria,   uiycdsui-ia   ny  syphilis.      'I'he 


Fig.   31 — Morton's   Oplithalmosrope. 


white  patches  upon  the  retina — albuminuric  retinitis — which  are  seen 
in  Bri.sht's  disease  have  often  revealed  the  malady  when  entirely  un- 
suspected. 

Cataract.     Diabetes  is  a  well  cstalilislird  cause  of  cataract. 


SECTION  IV. 

SYMPTOMS  OF  PATHOLOGIC  CONDITIONS 
OF  THE  CHEST. 

COUGH. 

Among  the  adventitious  sounds  one  which  plays  a  most  prominent 
j-ole  is  cough,  and  while  its  presence  does  not  always  indicate  de- 
rangements of  the  respiratory  apparatus  yet  by  reason  of  its  para- 
mount importance  as  a  physical  sign,  and  its  almost  universal  asso- 
ciation with  all  pathologic  changes,  however  slight,  in  the  breathing 
and  vocal  apparatus,  it  is  best  considered  along  with  the  pulmonary 
adventitious  sounds. 

Cough  is  a  sudden,  single  or  multiple  violent  expiratory  effort, 
spasmodic  in  origin,  with  the  object  of  expelling  some  irritating  sub- 
stance from  the  air  passages.  Each  cough  is  accompanied  by  a  sudden 
opening  and  closure  of  the  glottis  .so  that  the  air  is  expelled  in  foi-cible 
blasts. 

The  character  of  a  cough  varies  greatly,  not  only  during  the 
course  of  any  single  disease,  but  varies  likewise  with  the  multifarious 
pathologic  conditions  which  originate  it.  In  the  beginning  of  some 
diseases  it  is  so  characteristic  that  the  nature  of  the  affection  may  be 
foretold  by  the  cough  alone.  "With  the  progress  of  the  disease  this  dis- 
tinctiveness is  often  lost,  as  in  phthisis,  while  in  other  maladies,  as 
whooping  cough,  it  develops  as  the  disease  progresses. 

Coughs  are  dry  or  moist  as  to  whether  they  are  or  are  not  accom- 
panied by  expectoration.  According  to  the  location  of  the  disease 
which  originates  it  cough  is  spoken  of  as  laryngeal,  tracheal,  bronchial, 
■cardiac  or  sjinpathetie.  The  possibility  of  stomach  cough  in  the  sense 
used  by  the  older  writers  is  now  generally  denied. 

Dry  coughs  are  indicative  of  the  primary  stage  of  almost  all  in- 
flammatory affections  of  the  larynx  and  pulmonary  system.  In  pleu- 
risy and  the  early  stage  of  phthisis,  dry  cough  is  significant. 

Coughs  due  to  pressure  of  various  growths  upon  nerve  trunks 


!)L'  nlACNDSiS     l)K     I'ATIIOlAKilC     ( '( tNDrrlllNS     (IF     THIO     CIll'IST 

assiH'iatt'd  witli  tlic  rrs|iiratciry  Irad.  pai  I  iciilaily  sui'li  as  invnlvr  llnj 
recurrent  larynt;'eal  ni'i-vc.  Ihc  riiiiLili  nl'  caiMlinc  an'ci'l  idiis.  tlioraeic 
aiuMirysnis  and  soiih'  ntlicr  coiulil  ioiis.  rrinaiiis  dry  I  hi'ouiihout  its 
course  or  is  accompanied  liy  so  little  expectoration  as  to  merit  that 
distinction.  Ii'ritation  of  I  lie  air  passajies,  whether  intlanuiiatoi'y  or 
non-intlammatory,  will  likewise  cause  di'v  coujih,  as  nasal  polypi,  rhin- 
itis, acute  and  chronic  iutiammatiou  of  the  fauces  or  tonsils,  elonj^ated 
uvula  and  hypertrophied  tonsils.  A  similar  coufih  is  caused  by  many 
ailments  the  seat  of  which  is  entirely  removed  from  the  air  tracts,  and 
while  the  relation  of  cause  and  effect  is  indubitable,  yet  from  the  man- 
ner of  their  production  they  must  be  classified  as  sympathetic.  Thus, 
dentition,  intestinal  parasites,  various  organic  diseases  of  the  brain, 
the  stomach,  the  intestines,  the  heart  or  the  blood  vessels  numbei- 
cous'h  amon^  their  symptoms.  Diseases  productive  of  dropsies,  such 
as  changes  in  the  peritoneum,  kidneys,  liver  and  valvular  diseases  of 
the  heart  likewise  manifest  this  physical  sijjn.  It  is  a  cominon  mani- 
festation of  hysteria  and  states  of  high  nervous  excitement. 

Dry  cough  is  of  a  peculiar  irritant  character,  affecting  alike  both 
possessor  and  listener.  I  have  sometimes  attributed  this  impression  on 
'he  listener  to  the  undefined  sense  of  wasted  effort. 

A  careful  .study  of  the  varying  character  of  cough  in  its  many 
phases  is  instructive.  Laryngeal  cough  is  ringing  and  brassy,  although 
the  voice  is  husky;  nasal  and  pharyngeal  coughs  are  "hawking  and 
hemming"  in  character.  The  cough  of  croup  is  so  characteristic  as  to 
originate  the  ad.ieetive  "croupy. "  That  of  false  croup  is  husky, 
1  aueous,  stridulous  and  brassy.  The  most  noticeable  (|uality  of  chronic 
laryngeal  eouuh  is  hoarseness.  Likewise  vocal  hoarseness  accompanies 
most  other  laryngeal  disorders.  The  cough  of  emphysema  is  loud, 
harsh,  wheezing  and  paroxysmal.  The  characteristic  spasmodic  cough 
of  whooping-cough  is  so  well  known  as  scarcely  to  need  description. 
It  consists  of  a  violent,  protracted  series  of  abrupt,  forcible  expiratory 
efforts,  followed  by  a  long-drawn  inspiration  which  is  accompanied  by 
a  hoarse  noise  called  the  whoop,  from  the  similarity  of  the  sound  to 
the  syllable.  The  cough  usually  continues  with  brief  interruptions 
until  expectoration  or  vomiting  supervenes,  only  to  be  repeated  again 
after  varying  brief  intervals.  Prior  to  the  development  of  the  whoop, 
which  appears  at  the  end  of  the  fir.st  week,  the  disease  presents  no 
signs  which  distinguish  it  from  ordinary  catarrhal  bronchitis,  more  or 
less  of  which  is  associated  with  it  thronghout  its  course. 


DIAGNOSIS    OF    PATHOLOGIC     CONDITIONS    OF     THE    CHEST  93 

Commonly  associated  with  certain  coughs  is  an  annoying  tickling 
sensation  in  the  throat,  the  patient  frequently  observing  that  if  the 
tickling  were  stopped,  the  cough  would  disappear. 

Cough  is  affected  by  position,  being  usually  worse  during  the 
recumbent  posture:  by  time,  being  usually  worse  at  night,  or,  as  in 
chronic  bronchitis  and  phthisis,  worse  in  the  early  morning. 

EXPECTOEATIOX. 

Expectoration  is  the  consummation  of  such  coughs  as  progress 
through  an  orderh-  sequence  or  which  belong  to  the  series  that  we  have 
designated  as  moist  coughs.  The  matter  expectorated  often  possesses 
such  physical,  ehemic  or  microscopic  characteristics  as  positively  to 
identify  the  source  and  character  of  the  disease,  as  in  phthisis,  pneu- 
monia, bronchitis,  abscess  of  the  lung  and  a  few  others. 

The  amount  of  sputum  expectorated  varies  largely  with  the  dis- 
ease and  may  reach  1000  cc.  in  twenty-four  hours.  The  consistency  of 
the  sputum  varies  greatly,  as  a  rule  it  is  less  when  the  amount  is  great. 
The  consistency  is  extreme  in  the  first  stage  of  acute  pneumonia, 
bronchitis  and  phthisis.  In  these  cases,  especially  in  pneumonia,  it  is 
a  familiar  fact  that  the  sputum  cup  may  be  inverted  without  loss  of 
the  jelly-like  contents.  Sputum  containing  air  floats,  while  denser, 
airless  masses  sink.  Very  dense  sputum  assumes  round  or  flat,  disc- 
like  shapes,  and  when  such  masses  float  in  thinner  expectoration,  we 
have  the  coin-like  or  nummular  sputum,  of  which  the  cavities  of  tuber- 
culosis give  us  the  best  examples.  Small,  cheesy  particles  which  sink  to 
the  bottom  of  the  cup  are  likewise  indicative  of  phthisis  and  usually 
contain  large  nitmbers  of  tubercle  bacilli.  In  cases  of  pulmonary 
tedema  the  fluid  expectorated  is  thin,  serum-like  and  covered  with 
froth.  The  sputa  of  pulmonary  gangrene,  of  perforated  empyema 
and  of  pulmonary  abscess  may  be  composed  almost  entirely  of  pus. 
which  may  possess  a  strong,  distinctive  odor.  The  color  of  the  sputa 
varies  from  the  transparency  of  mucoid  expectoration  to  the  dark- 
brown  or  red  of  admixed  blood.  The  white  color  indicates  leucoc\i:es, 
yellow  and  green  sputa  are  purulent,  bile  pigment  also  gives  a  green 
color  to  the  expectoration.  Red  denotes  blood.  Pulmonarj^  gangrene 
gives  rise  to  a  fetid,  chocolate-colored  sputum.  This  form  of  sputum 
contains  various  elements  deserving  of  more  particular  mention,  such 
as  elastic  tissue  fibers,  the  presence  of  which  always  denotes  some  de- 
structive process  in  the  pulmonary-  tissue.    Such  destruction  occurs  iu 


1)4  DIAllNiiSlS    111''     I'.\TIl()I.(UilC     cnMIITKINS     OF     Till",     ClIKST 

phthisis  and  aiiscess  as  well  as  in  gaiii,nviu'.  lii  Joriner  days  the  recog;- 
iiition  of  these  libers  was,  taken  in  eoniieetion  with  other  piiysical  signs, 
the  surest  indication  of  phthisis  at  the  command  of  the  diagnostician. 
Fibrinous  casts  are  found  in  the  sputa  in  the  course  of  pneumonias 
and  sometimes  in  bronchitis.  They  may  ho  i-ecognized  by  the  eye  and 
beautifully  demonstrated  by  sliakiim  them  with  a  litllr  water  in  a 
large  test  tube. 

The  sputum  of  bronchial  asthma  is  very  distinctive  and  finds  no 
counterpart  in  any  othei-  atfection.  It  contains  small,  translucent 
pellets  or  gelatinous  masses,  named  by  Laennee,  "perles".  These  ball- 
like masses,  when  unfolded,  are  found  to  be  mucous  moulds  of  the 
smaller  tubes.  The  entire  sputum  may  consist  of  these  bodies  floating 
in  thin  mucus.  If  a  portion  of  the  sputum  be  spread  on  glass  and 
held  over  a  dark  background,  it  will  be  found  that  among  these  masses 
are  some  which  have  a  twisted  or  spiral  shape  recognizable  by  the 
naked  eye,  others,  when  unravelled  and  viewed  under  the  microscope 
present  the  same  structui-e.  They  assume  one  of  two  forms.  In  the 
first  a  few  mucin  fibrils  are  twisted  upon  each  other  and  enclosed 
in  their  meshes  are  entangled  a  small  number  of  leueocj'tes,  generally 
eosinophiles  of  large  size  and  containing  numerous  fine  granules  stain- 
able  with  eosin.  In  the  second  form  the  mucin  fibrils  are  much  more 
luimerous  and  are  tightly  twisted  around  a  crooked  central  fiber.  En- 
closed within  the  skein  are  a  few  cells.  Curschmann  views  the  threads 
as  transformed  mucin  formed  in  the  finest  tubes  as  the  result  of  a 
bronchiolitis.  It  has  been  stated  that  these  bodies  have  been  found  in 
the  sputa  of  chronic  bronchitis  and  of  croupous  pneumonia,  but  O-sler 
says  he  has  never  found  them  therein. 

The  above-described  sputa  often  contain  jiointed  octahedral  crys- 
tals first  described  by  Leyden  and  called  Charcot-Leyden  crystals. 
They  occur  later  in  the  attack,  while  the  spirals  are  found  early.  If, 
however,  the  sputum  containing  the  spirals  be  kept  for  several  days  it 
is  said  that  the  crystals  will  develop  from  the  spirals.  These  crystals 
are  found  very  occasionally  in  acute  and  chronic  bronchitis  and 
phthisis.  Under  the  microscope  they  appear  either  as  small,  straight 
hexagonal  prisms  or  as  granules  of  varying  size :  they  are  quite  gener- 
ally associated  with  free  eosinophilic  leucocytes  as  already  stated.  The 
ery.stals  are  found  in  the  blood  in  myelogenous  leukaemia. 

The  boiled  sago-like  grains  which  often  appear  in  the  sputum  are 
due  to  the  i)resenee  of  alveolar  cells  which  have  undergone  invelin 


DIAGNOSIS    OF    PATHOLOGIC     CONDITIONS    OF     THE    CHEST  9& 

degeneration  and  are  merely  indicative  of  a  catarrhal  process  without 
other  -distinctiveness,  although  they  are  often  encountered  in  early 
phthisis. 

The  presence  of  tubercle  bacilli  and  the  diplococcus  pneumonite, 
and  the  methods  of  demonstrating  them  by  stains,  are  discussed  under 
their  appropriate  headings. 

HAEMOPTYSIS. 

Definition.  Haemoptysis  is  the  expectoration  of  blood  which  has 
escaped  into  the  air  passages.  Occasionaly  blood  escapes  into  a  cavity 
which  is  not  in  communication  with  a  bronchus,  in  which  case  there 
is  no  expectoration  of  blood.  ■  Thus  there  may  be  extravasation  of 
blood  into  the  pleural  sac  or  a  pulmonary  aneurysm  may  rupture  into 
a  cavity  which  has  no  communication  with  the  air  tubes. 

Causes.     The  most  common  causes  of  haemoptysis  are  : 

(a)  The  rupture  of  an  aneurysm  on  some  branch  of  the  pul- 
monary artery. 

(b)  Erosion  of  a  branch  of  the  pulmonary  artery  due  to  disease 
of  '"hatever  nature.  Such  haemorrhages  occur  during  the  advanced 
stages  of  phthisis,  bronchiectasis,  cancer  and  occasionaly  in  gangrene 
of  the  lung. 

(c)  Active  or  passive  hyperajmia  of  either  the  bronchial  or  pul- 
monary capillaries.  In  this  case  the  quantity  of  blood  is  small  com- 
pared with  the  other  lesions.  Such  hfemoptysis  occurs  at  the  outset 
of  phthisis,  in  acute  broncho-pneumonic  phthisis,  in  acute  miliary 
tuberculosis,  bronchiectasis,  cirrhosis  of  the  lung,  emphysema,  in  the 
initial  stages  of  pneumonia  and  bronchitis;  in  pulmonaiy  gangrene, 
cancer,  abscess,  in  short,  all  inflammatory  diseases  of  the  lung.  In 
these  eases  the  quantity  is  often  only  sufficient  to  streak  the  sputa. 

(d)  Injuries  to  the  lungs  and  pleura,  tumors  and  parasitic  in- 
vasions and  all  forms  of  pleurisy  may  give  rise  to  haemorrhage. 

(e)  In  young,  healthy  persons  haemoptj'sis  may  arise  without  any 
assignable  cause,  without  warning,  continue  a  few  days  and  pass 
away  without  leaving  any  subsequent  token  of  its  visitation,  and  the 
attack  may  never  be  repeated. 

(f)  Hcpmoptysis  occurring  with  lesions  of  the  cardiac  valves, 
particularly  in  mitral  insufficiency  and  mitral  stenosis  and  in  aortic 
insufficiency.  Here  it  may  be  profuse  and  recur  at  regular  intervals 
for  vears. 


9(J  UIAUXOSIS     OF     I'ATllDl.lllllC     (■oM)|TlllNS     l)K     TllK     (■  1 1  IlST 

(ir)  Hiemoptysis  accuinpaiiyiiii:  ctTtain  iniinivcrisliiiifiils  nl'  lin' 
blood,  particularly  rickets,  scurvy,  inirpura,  luviuophilia  aud  occasion- 
ally leucocythaiiuia.  Tiider  this  head  may  he  included  the  lucuioptysis 
of  lualisnant  fevers. 

ricerative  affections  oi'  Ihc  hirynx,  ti'aclu'a  and  bronchi  ;jivc  rise 
to  hu-niorrhages  which  may  be  profuse  and  rapidly  fatal.  Such  ulcer- 
ation may  occur  even  in  bronchitis.  Aneurysm  of  the  aorta  may  ulcer- 
ate into  a  brouchus  or  the  trachea.  Vicarious  luenioptysis  replacing 
menstruation  is  too  well  established  to  be  denied.  A  recurrent 
haemoptysis  of  arthritic  subjects  is  described  by  Sir  Andrew  Clark. 
In  these  cases  the  patient  is  beyond  fifty  years  of  age,  the  hiemorrhages 
recur  without  any  serious  disease  of  the  \unu.s  being  present  or  devel- 
oping after  the  attack. 

Character  of  the  expcdorali  rl  hlmid.  'i'he  (|uanti1y  varies  IVmii 
a  mere  show  to  a  litre,  the  rupture  of  an  aortic  jiiicuiysni  into  a 
bronchus  may  amount  to  the  latter  (|uantity.  Tlic  hjond  is  l)riv;ht-red 
when  moderate  in  amount,  but  if  enormous  may  be  dark  or  venous- 
colored.  It  is  mixed  witli  the  bronchial  secretions  formed  in  the  vari- 
ous diseases  with  which  it  occurs.  When  in  any  considerable  amount 
it  is  frothy  from  admixture  of  air.  The  blood  of  hiemoptysis  is  alkaline 
in  reaction,  a  point  which  serves  to  distinguish  it  from  blood  derived 
from  the  stomach.  If  it  is  retained  for  some  time  within  the  lungs 
it  coagulates  and  its  color  is  dark-brown  or  black.  It  is  then  often 
coughed  up  in  strings  or  moulds  of  the  bronchioles.  For  several  days 
after  a  ha'morrhage  the  secretions  will  be  stained  with  l)ro\vTiish 
streaks. 

Symploms.  These  vary  with  the  gravity  of  the  attack.  When 
large  quantities  of  blood  are  suddenly  lost  the  symptoms  are  more 
grave  than  when  a  like  quantity  of  blood  is  more  slowly  lost.  In  the 
graver  cases  blood  may  pour  out  of  the  nose  and  mouth  or  it  may  be 
coughed  up  in  gulps.  Blood  which  has  been  swallowed  uuiy  be  after- 
wards vomited  or  be  passed  by  the  bowels. 

The  symptoms  are  great  pallor  and  anxious  expi-ession  of  face, 
cold,  clammy  skin,  small  feeble  pulse,  faintness  and  coldness  of  the 
extremities.  During  the  attack  there  is  a  decided  fall  of  temperature, 
but  subsequently  a  febrile  reaction  sets  in,  the  temperature  rapidly 
rising  to  102°  or  104°  F.,  then  falling  by  gradations  for  several  suc- 
cessive days.  This  fever  will  continue,  especially  in  tuberculous  cases, 
for  several  days  to  a  week,  even  in  patients  where  there  was  little  ele- 


DIAGNOSIS    OF    PATHOLOGIC     CONDITIONS    OP    THE     CHEST  97 

vation  prior  to  the  accident.  The  haniiorrhages  of  piihnonary  tuber- 
culosis may  be  separated  by  wide  intervals  and  some  tuberciilous  cases 
terminate  without  any  distinct  ha?moptysis.  while  other  cases  are 
marked  by  periodical  recurrences. 

If  haemorrhage  comes  from  a  ruptured  pulmonary  aneurysm  the 
quantity  is  apt  to  be  large,  but  if  the  termination  is  not  fatal,  the 
opening  closes  and  the  danger  passes.  If  a  vessel  erodes  the  closure  is 
by  clot,  which  may  be  dislodged,  allowing  a  repetition  of  the  ha?m- 
orrhage  at  intervals  of  a  day  or  two,  as  is  often  observed. 

Diagnosis.  Inspection  of  the  front  of  the  chest  and  auscultation 
with  a  stethoscope  may  be  made  during  the  continuance  or  imme- 
diately after  the  haemorrhage,  but  no  attempt  at  percussion  nor 
change  in  the  position  of  the  patient  is  permissible,  neither  should  he 
be  allo\Yed  to  speak,  cough  or  even  breathe  deeply.  A  few  moist  rales 
may  be  heard  towards  the  apex.  A  previous  knowledge  of  the  presence 
or  absence  of  tuberculous  signs  is  most  useful.  The  heart  may  be 
examined  early,  in  order  to  ascertain  whether  or  not  the  valves  of 
that  organ  be  diseased. 

Difficulty  is  often  encountered  in  determining  from  the  history 
of  a  case  whether  a  previous  attack  has  been  one  of  haemoptysis  or  of 
ha?matemesis.  If  the  patient  is  seen  during  the  attack  the  differen- 
tiation is  easy.  In  case  of  a  previous  seizure,  it  should  be  ascertained 
whether  the  patient  had  suffered  from  cough,  expectoration,  shortness 
of  breath  and  other  symptoms  i-eferable  to  the  lungs,  or  whether  he 
had  previous  to  the  attack  dyspepsia,  vomiting  or  other  gastric  symp- 
toms, or  gives  a  history  of  hepatic  disease,  particularly  cirrhosis.  Per- 
haps splenic  enlargement  may  be  made  out.  These  three  organs  are 
the  chief  malefactors  in  hsematemesis,  while  the  lungs,  the  heart  and 
the  vessels  assume  the  same  roles  in  haemoptysis.  The  history  may 
show  whether  previoiis  or  subsequent  to  the  attack  the  sputvim  was 
streaked  with  blood,  and  whether  faintness  preceded  it.  Sometimes 
also,  in  the  case  of  intelligent  patients,  one  can  ascertain  other  valuable 
facts,  as  to  whether  the  attack  came  on  during  a  fit  of  coughing  or  of 
vomiting,  and  whether  or  not  the  blood  came  all  at  once  or  in  successive 
mouthfuls. 

The  common  recital  of  the  patient  in  the  case  of  hemoptysis  is 
that  he  "felt  a  tickling  in  the  throat,"  or  "had  a  salty  taste  in  the 
mouth,  followed  by  the  blood."  Such  a  description  does  not  apply 
to  hffimatemesis. 


!I8 


DIAliNOSIS    OF    I'ATUOl.OUIC     CONDITIONS    OK     THE    CUEST 


III  lui'matemesis  the  blood  is  dark  in  color,  acid  iu  reacliou;  if  it 
has  remained  long  enough  in  the  stomach  to  be  acted  ou  by  the  gastric 
juice  it  resembles  colt'ee-grouuds.  It  may  be  mixed  with  food.  It  is 
generally  clotted.  Vomiting  is  often  preceded  by  a  sense  of  faintness. 
The  passages  subsequent  to  the  attack  are  tarry,  but  it  must  not  be 
forgotten  that  during  an  attack  of  ha'moptysis  blood  is  frequently 
swallowed,  to  be  afterwards  vomited  or  passed  from  the  bowels.  For 
convenience  we  arrange  the  above  syinptoms  in  iiMrallcl  rolumns,  as 
an  aid  to  differentiation. 


Hamoptyds. 

1.  History  and  symptoms  of 
pulmonary  disease.  Cough,  moist 
rales.  Signs  of  cardiac  valvular 
disease. 

2.  Sputa  blood-streaked  before 
and  after  the  attack.  Attaclc 
comes  on  during  coughing.  If 
vomiting,  it  is  sub.sequent  to 
seizure. 

■3.  Blood  aerated,  alkaline  in 
reaction,  frothy,  bright-red  in 
color,  clots  i-eadily;  mixed  with 
pulmonary  secretions,  pus. 

4.  Local  physical  signs. 


Ilccmalimcsis. 

1.  History  of  disease  of  stom- 
ach, lii'er  or  spleen:  enlargement. 
No  physical  signs  of  valve  dis- 
ease. 

2.  Attack  comes  on  during 
vomiting,  often  preceded  by 
faintness.     Blood  comes  en  masse. 


'■].  Blood  dark-l)rown  or  black 
in  color,  acid  in  reaction,  mixed 
with  food,  usually  in  coarse  clots, 
or  coffee-grounds. 

4.  Mekmia  and  nausea  eubse- 
((uent.     Local  physical  signs. 


The  following  signs  of  all  severe  internal  hasmorrhages  are  com- 
mon to  both  conditions,  viz.,  restlessness,  extreme  pallor,  a  quick, 
feeble  puke,  syncope,  subnormal  temperature,  skin  clammy  or  bedewed 
with  cold  perspiration,  breathing  shallow  and  feeble  but  hurried,  great 
thirst.  In  fatal  cases  consciousness  is  apt  to  be  retained  longer  in 
haemoptysis  than  in  haematemesis,  since  the  stomach  loses  its  power  to 
expel  the  blood  earlier  than  do  the  lungs. 

In  cases  not  presenting  the  ordinary  physical  signs  the  larynx 
should  be  examined  for  a  ruptured  vessel  or  ulceration,  as  mentioned 
under  causes. 

Syphilis  of  the  trachea  and  bronchi  is  also  an  occasional  cause  of 
hipniorrhage.  likely  to  be  overlooked. 


DIAGNOSIS    OF    PATHOLOGIC     CONDITIONS    OF     THE     CHEST  99> 

DYSPN(EA. 

Difficult  breathing  accompanies  a  variety  of  disorders  of  very 
diverse  character.  Sometimes  it  is  the  direct  result  of  gross  lesions 
of  the  respiratory  or  circulatory  s.ystems,  at  others  it  is  due  to  the 
presence  within  the  organism  of  toxic  materials  and  occurs  wholly 
apart  from  discernible  lesions.  In  still  other  cases  sub,jective  causes, 
as  pain  or  even  hysteria,  are  responsible  for  its  presence.  Certain 
constitutional  vices,  as  rickets,  while  not  wholly  accounting  for  its 
oncoming,  are  yet  contributory  and  augment  it  when  present. 

Among  diseases  of  which  dyspnoea  is  a  well  recognized  symptom, 
asthma,  of  either  the  bronchial  or  cai'diac  tj'pe,  stands  in  the  front 
rank.  Of  the  former  variety  it  is  the  leading  symptom.  Further- 
more it  is  seen  in  all  inflammations  of  the  respiratory  tract  from  the 
Schneiderian  membrane  to  the  ultimate  air  cells.  It  occurs  with 
eoryza,  with  nasal  polypi,  hypertrophy  of  the  tonsils,  retro-pharyn- 
geal,  oesophageal,  or  fauceal  abscess,  and  quinsy.  It  is  characteristic 
of  obstructive  inflammations  of  the  larj^nx,  as  diphtheria,  of  new- 
growths  or  paralysis  of  the  organ,  and  of  the  spasmodic  condition 
known  as  laryngismus  stridulus.  In  catarrhal  inflammations  of  the 
larynx  it  plays  a  less  prominent  role.  The  diseases  of  the  trachea,  the 
bronchi  and  the  lungs  of  which  it  is  a  symptom  are  more  particularly 
described  in  this  work.  It  may  be  said  to  be  associated  in  varying: 
degree  with  the  entire  list,  as  well  as  with  those  of  the  pleura.  Ad- 
mission of  air  into  the  pleural  sac,  as  from  ulceration,  may  cause  its. 
sudden  onset,  as  does  also  perforation  from  without.  Cancer  of  the 
respiratory  tract,  and  especially  cicatrices  resulting  from  previous; 
ulceration,  are  included  in  the  etiology. 

Its  intimate  association  with  all  forms  of  heart  disease  is  well 
known,  and  here  it  often  forms  a  safe  barometer  indicating  plainly,,, 
by  its  rise  and  fall,  not  only  the  state  and  progress  of  the  disease,  but', 
likewise  the  efficacy  of  the  treatment.  It  accompanies  endocardial  ani 
pericardial  inflammations.  Intrathoracic  growths  are  causes,  both; 
directly,  through  the  obstruction  which  they  produce,  and  indirectly,, 
by  their  influence  upon  the  respiratory  nerve  mechanism  (see  Aneur-- 
ysm).  Acute  mediastinal  lymphadenitis  gives  rise  to  paroxysmal 
dyspnoea ;  de  Mussy  holds  that  the  dyspncea  of  whooping  cough  is  due- 
to  this  cause.  Thrombosis  and  embolism  of  the  pulmonary  vessels, 
as  well  as  cerebral  embolism,  are  occasional  but  grave  causes.  Any- 
condition  which  materially  alters  the  intrathoracic  pressure,  operating; 


1(1(1  DIAdXiiSIS    III-     I'ATlloI.odlC     foXniTUINS    ()!•'     TdlO     CIIIOST 

eiUior  i'roiii  within,  as  (.iiiphysfiua  oi-  ell'iisioiis  iulo  tlu'  |)k'iiral  (ii- 
pericardial  sacs,  or  operating  from  without,  as  tumors,  hypertropiiies 
and  dropsies  below'  the  diaphragm,  may  likew'ise  cause  dyspmea.  Kid- 
ney diseases,  unaccompanied  by  dropsy,  owing  to  faulty  elimination 
manifest  it,  and  in  uranuia  it  assumes  a  peculiar  type.  Its  intercur- 
rence  during  the  course  of,  or  during  convale-scence  from  scarlet  fever 
should  suggest  scarlatinal  nephritis.  It  is  presiMit  in  apoplexy,  ci'i-c- 
bial  tumors  and  other  diseases  of  both  In-ain  and  cDid.  Alcohol  and 
toxic  substances  absorbed  into  the  blood,  as  well  as  changes  in  the 
blood  itself,  are  known  factors,  hence  its  share  in  the  .symptom-group 
of  the  anaemias.  In  progressive  pernicious  antemia  it  progresses  with 
the  case  and  is  the  type  of  the  so-named  amumie  dyspnrea.  In  lai-gf 
goitres  and  in  Ludwig's  angina  dysjiiKea  I'csnits  from  traciieal  com- 
pression. 

The  dyspna'a  of  obesity  is  a  matter  of  daily  observation. 

Classification.  Dyspnceas  may  be  classified  as  mechanical,  clii m- 
ical,  and  nervous.  The  first  includes  all  those  forms  which  arise  from 
pressure  and  obstruction,  thereby  causing  a  reduction  of  the  air  cur- 
rent ;  from  deformities  and  from  lesions  which  result  in  hypostasis. 

Chemical  causes  are  toxicity,  imperfect  aeration  and  the  accumu- 
lation of  CO^,  as  occurs  in  febrile  diseases  and  faulty  elimination. 

Nervous  and  reflex  causes  include  spasmodic  eases,  att'ections  of 
the  respiratory  center,  peripheral  irritations,  and  palsies. 

In  many  cases  two  of  these  factors  iinite  to  produce  the  dyspmea. 
.According  to  its  relation  to  respiratory  rhythm  we  classify  dysjimea 
;as  inspiratory  or  expiratory. 

Appearances  a)id  Physical  Signs.  The  dyspnu'a  may  be  plainly 
•manifested  by  the  expression  and  attitude  of  the  sufferer,  the  marked 
(evidences  of  pain,  the  appearance  of  labored  breathing,  the  cyanosis 
or  the  pallor  of  the  skin,  or  the  noises  which  accompany  the  respira- 
tory acts.  The  respirations  may  be  lessened  in  number,  but  ai-e  much 
oftener  increased.  Normally  the  number  of  respirations  is  18  to  20 
per  minute  for  men,  and  20  for  women.  In  children  the  number  va- 
ii-ies  with  age,  being  45  per  miniite  at  birth,  25  at  the  fifth  year,  decreas- 
ing to  18  at  the  fifteenth  year.  The  number  of  respirations  is  intln- 
fuced  in  health  by  the  same  causes  which  increa.se  or  diminish  the 
pulse  rate  (see  Pulse).  The  relation  of  the  breathing  rate  to  the  pulse 
rate  is  one  to  four,  or  one  to  four-and-a-half,  in  health.  The  num- 
ber should  be  reckoned  without  undulv  attracting  the  attention  nf  the 


DIAGNOSIS    OF    PATHOLOGIC    COXDITIOXS    OF     THE    CHEST  101 

patient,  since  this  consciousness  involuntarily  increases  the  number. 
Oft  times  the  movement  of  the  bed-clothes  suffices  for  ascertaining  the 
number.  If  the  breath-pulse  ratio  above  given  is  much  exceeded,  we 
may  suspect  that  the  disorder  has  to  do  vrith  the  respiratory  function, 
while  if  the  pulse-breath  ratio  is  altered  materially,  the  probability  is 
that  the  circulation  is  at  fault.  A  pre\-ious  knowledge  of  the  con- 
dition of  the  patient  substantially  aids  in  the  appreciation  of  the 
situation,  since  in  aggravated  cases  a  complete  examination  may  be 
impossible.  Yet  even  here  valuable  information  is  afforded  by  vis- 
ible signs,  as  pulsation,  the  presence  of  oedema,  anasarca,  signs  of 
pressure,  of  spasm  or  obstnietion,  collections  of  fluids,  or  even  of  exu- 
dation into  the  air  cells.  Perhaps  the  heart-sounds  may  be  listened  ta 
■i^ithout  greatly  adding  to  the  discomfort  of  the  patient.  Careful 
attention  to  the  neck,  throat  and  abdomen  is  recommended.  Dilata- 
tion of  the  nares  accompanies  inspiratory  dyspncea.  The  accompany- 
ing sounds  may  aid  in  locating  the  seat  of  the  disease,  as  well  as  inti- 
mating its  nature.  In  obstruction  of  the  larynx  or  trachea,  or  spasm 
of  the  cords,  the  sounds  are  loud,  rough,  vibrating  or  snoring,  and 
the  auxUiarj-  muscles  of  respiration  are  brought  into  play.  Some- 
times the  sounds  suggest  a  valve-like  obstruction  to  inspiration,  and 
the  act  ends  in  an  abrupt  croak  or  squeak,  as  in  lai-jiigeal  diphtheria. 
Abscess  about  the  fauces  or  inflammation  of  the  tonsils  imparts  a  pe- 
culiar hoarseness  and  choking,  and  is  accompanied  by  incessant  efforts 
to  expel  the  viscid  secretions.  Affections  of  the  glottis,  ulcerations  and 
tumors  of  the  lar^-nx,  give  to  respiration  a  crowing  soimd  or  a  stridu- 
lous  character.  Bronchial  obstruction,  when  sufficient  to  cause  con- 
siderable disability,  imparts  a  whistling  or  wheezing  note  to  the  respir- 
ation, which  may  be  heard  only  on  inspiration,  or  on  both  inspiration 
and  expiration.  Fluids  give  rise  to  rales  or  gurgling  sounds.  Pneu- 
mothorax sometimes  is  accompanied  by  a  sighing  or  gasping  breath. 

Cough  occurs  in  no  inconsiderable  proportion  of  dyspnoeas,  as 
readily  would  be  concluded  from  scanning  the  list  of  eavLses.  Fits  of 
coughing,  as  a  rule,  increase  the  dyspnoea,  or  the  dyspncea  may  occui" 
only  during  and  after  coughing,  as  in  pertussis.  In  almost  all  con- 
solidations of  pulmonary  substance  the  same  observation  holds  good. 
Expectoration  generally  brings  relief,  as  in  bronchiectasis. 

The  term  dyspncea  is  not.  however,  confined  to  the  phenomena 
above  described,  in  which  the  breathing  is  manifestly  labored,  and  in 
which  auxiliary-  aid  is  sought.    The  term  is  quite  as  applicable  to  those 


1(L'         |)IA(;N(isis   oi''    i-ai'ihikiicic    cdxhitio.ns    of    tiik    iuiiost 

diseases  iu  which  a  dccidrd  iiicrt'asi'  in  the  lunnlirr  nf  rcspirMtioiis  oc- 
curs without  piU'ticiihir  ell'cirt  us  is  sei'ii  in  iJiiciunoiiiii,  in  which  the 
rate  may  rise  to  60  or  even  80  per  minute.  This  form  belongs  properly 
to  tlie  second  division  of  our  classification,  viz.,  Chemical  Form. 

Allied  to  the  latter  form  is  the  dyspnoea  which  occurs  upon  ex- 
tM'tioi'  The  patient  may  be  quite  comfortable  so  long  as  he  remains 
■quiet  or  recumbent,  but  the  exertion  of  sitting  up  brings  on  an  altaclc. 
Such  dyspna'a  occurs  frequently  in  convalescence,  but  is  not  enn- 
fined  within  its  boundaries.  In  andther  variety  the  palieni  ina\-  lie 
free  from  discomfort  so  long  as  he  walks  on  a  level  or  walks  at  a 
moderate  pace,  but  should  he  attempt  a  slight  ascent,  or  should  the 
necessity  to  quicken  his  pace  arise,  the  attack  sets  in.  This  may  be 
the  first  admonition  to  the  patient  that  his  mechanism  is  deranged. 
Dyspnoea  in  young  children  often  shows  itself  in  the  inability 
•of  the  child  to  nurse,  although  obviously  anxious  to  do  so.  'i'he  neces- 
:sity  for  breath  causes  it  quickly  to  relinquish  the  effort.  This  is  espe- 
•cially  marked  in  nasal  and  lai-yngeal  aft'ections,  either  obstructive  or 
spasmodic. 

Cardiac  dyspniea  may  come  on  suddenly  or  gradiiall.w  after  ex- 
ertion or  when  the  subject  has  been  perfectly  quiet.  It  is  often  ac- 
■companied  by  excessive  pain.  The  resemblance  of  this  affection  to 
bronchitic  asthma  has  given  it  the  name  of  cardiac  asthnui.  The 
.spasmodic  nature  and  the  absence  of  mechanical  causes  point  to  the 
nerve  influence  as  an  etiological  factor.  It  not  infrequently  comes  on 
suddenly  during  the  night.    Its  causes  have  been  already  listed. 

The  peculiar  sudden  dyspn(pa  of  pulmonary  embolism  is  described 
in  that  section. 

Xervous  dyspna'a,  the  third  class,  has  already  been  touched  upon 
l)y  reason  of  the  impossibility  of  completely  separating  the  three 
•classes.  It  is  apt  to  be  combined  with  mechanical  causes,  since  pres- 
sure and  peripheral  irritations  of  nerve  terminals  are  potent  factors 
in  exciting  spasm  and  other  evidences  of  refiex  action.  Hence,  in  diph- 
theria, in  all  forms  of  laryngeal  inflammation,  irritations  the  result  of 
of  growths  or  foreign  bodies  in  larynx  or  trachea,  and,  as  already 
stated,  the  influence  of  an  aneurysm,  may  cause  alarming  and  even 
fatal  spasm  of  the  glottis.  The  nervous  influence  in  the  production 
of  bronchial  asthma  is  described  in  the  section  devoted  to  that  malady. 
That  it  is  the  result  of  transient  spasm  is  indicated  by  the  suddenness 
•with  which  it  comes  and  goes,  the  maimer  in  which  it  is  influenced  bv 


DIAGNOSIS    OF    PATHOLOGIC     CONDITIONS    OF     THE    CHEST  103 

iLer\ines,  and  the  influence  which,  certain  odors  or  irritants  when  in- 
haled exercise  in  the  development  of  the  attack. 

Hysterical  dyspnoea  belongs  to  this  category,  and  the  dyspnoea 
of  pregnancy  sometimes  seen  earh'  in  the  case,  apart  from  any  albn- 
minuria,  cardiac  or  kidney  lesions,  is  partly  mechanical  and  partly 
nervous.  The  dyspnoea  of  the  later  stages  is  almost  purely  mechan- 
ical. 

Eenal  dyspnoea  shows  itself  in  two  forms,  the  earlier  form  usu- 
ally appears  after  exertion  and  in  this  respect  closely  resembles  the 
corresponding  form  of  cardiac  dyspnoea.  The  second  form  is  probablj' 
of  nervous  origin,  and  markedly  resembles  spasmodic  bronchial 
asthma.  The  differential  diagnosis  between  the  two  forms  should  be 
based  upon  evidence  pointing  to  disease  of  the  one  or  the  other  organ. 
In  sooth,  the  various  forms  are  all  differentiated  by  signs  and  evi- 
dence confirmatory  of  pathologic  changes  sufficient  to  account  for  the 
attack  having  occurred  in  the  organs  and  tissues  involved,  and  by  the 
careful  exclusion  of  similar  changes  in  the  other  organs  which  might 
give  rise  to  corresponding  symptoms. 

Orthopncea  is  inability  to  breathe  while  lying  down ;  it  is  a  grade 
of  dyspnoea.  In  some  cases  it  is  so  severe  that  the  patient  must  sleep 
with  the  head  resting  on  the  arms  or  on  a  table.  While  the  patient 
may  be  able  to  bend  forward,  j^et  the  slighest  backward  tilt  brings 
a  sense  of  impending  suffocation.  Orthopncea  sometimes  occurs  in 
oedema  of  the  lungs,  in  high  graoles  of  pulmonary  congestion  and  in 
pleural  effusion,  but  usually  it  is  associated  with  some  cardiac  lesion 
or  with  an  advanced  aneurysm.  In  the  absence  of  signs  of  pulmonary 
involvement  the  probability  of  the  cardiac  origin  is  increased.  Peri- 
carditis may  cause  it,  particularly  when  adhesions  form.  Increased 
strain  thrown  upon  the  heart  in  the  course  of  other  diseases  which 
cause  lesser  grades  of  dyspnoea,  and  intercurrent  cardiac  com.plica- 
tions  may  produce  it ;  hence  it  may  be  paroxysmal.  The  assumption 
of  the  erect  posture  is  explained  by  the  fact  that  the  organs  are  less 
hampered  in  this  position,  the  auxiliary  muscles  are  more  easily  fixed, 
and  fluids  gravitate  to  levels  where  they  interfere  less  with  the  air 
interchange.  In  some  cases  a  satisfactory  explanation  is  not  apparent. 
CYANOSIS. 

Cyanosis  is  closely  related  to  dyspnoea,  and  great  dyspnoea  usu- 
ally presents  a  considerable  degree  of  cyanosis,  yet  each  may  occur 
without  the  other:  thus,  in  that  group  of  congenital  cardiac  defects 


1(14  [>IA(,XOSIS    OF     PATIHIl,(H;iC     CIINDITIOXS     OF     TlIK     CHEST 

kiiowu  as  coii^'eiiital  i-yaiiosis,  or  iiKirbus  caTulciis.  whili'  cyanosis  is 
the  most  evident  sign,  dyspna^a  may  be  wholly  lacking.  On  the  other 
hand,  severe  attaeks  of  tachycardia  may  be  attended  with  marked 
dyspnoea,  yet  cyanosis  be  lacking. 

Cyanosis  may  affect  the  entire  body,  or  only  liic  extremities  may 
.show  signs  of  it.  The  face  is  affected  in  all  except  the  lighter  grades. 
The  lips  and  the  finger-tips  are  the  first  to  give  evidence  of  it.  All 
diseases  interfering  with  the  entrance  of  air  into  the  lungs  cause 
cyanosis  directly  proportional  to  the  degree  of  interference.  Dis- 
eases and  conditions  interfering  with  tlie  normal  exchange  of  gases 
which  occurs  in  respiration,  and  which  permit  the  retention  of  COj 
within  the  body,  naturally  produce  cyanosis.  Hence,  (liiniiiution  of 
the  cell  areas  of  the  lung,  such  as  occurs  gradually  in  llu'  ciuii-se  of 
consolidations,  or  quickly,  as  in  compressions  and  exudations,  is  fol- 
lowed by  this  result.  Even  in  severe  bronchitis,  especially  of  children, 
a  considerable  degree  of  cyanosis  is  manifest.  Pneumothorax  exer- 
cises a  similar  influence.  In  pleurisy  it  increases  with  the  amount  of 
the  fluid. 

In  cardiac  diseases,  it  is  one  of  the  general  manifestations,  and 
increases  with  the  dyspnoea.  Diseases  involving  the  right  heart  mani- 
fest it  to  a  greater  degree  than  those  of  the  opposite  side.  It  is  marked 
in  tricuspid  disease. 

Conditions  of  the  blood  which  diminish  the  oxygen-carrying 
power  cause  lividity  and  cyanosis.  Thus,  it  is  seen  during  the  admin- 
istration of  ansEsthetics,  in  many  forms  of  poi.soning,  as  by  nitrous 
oxide,  after  a  dose  of  morphia,  the  inhalation  of  irrespirable  gases, 
especially  CO.,  and  coal-gas.  Diseases  and  neuroses  of  the  larynx 
which  cause  dyspnoea,  also  cau.se  cyanosis:  as  paralysis,  and  laryngis- 
mus stridulus  of  children.  In  the  chronic  infantile  stridor  of  Taylor 
and  Lee,  dyspnoea  is  without  cyanosis.  Acute  laryngitis  produces 
lividity  of  lips  and  finger-tips.  Laryngeal  diphtheria  may  iirodnee  a 
high  grade  of  general  cyanosis. 

The  chronic  cyanosis  of  heart  diseases  is  followed  by  permanent 
changes  of  an  indurative  nature,  as  pigmentation  and  sclerosis.  Cyan- 
otic indui-ation  is  described  in  connection  with  diseases  of  the  heart. 
CLUBBING  OF  FINGERS  AND   TOES. 

In  various  chronic  disease  of  the  chest  there  occurs  a  thickening 
and  curving  of  the  finger  ends  and  to  a  less  degree  of  the  toes  and 
the  nose,  to  which  the  name  of  clubbing  is  given. 


DIAGNOSIS    OF    PATHOLOGIC     CONDITIONS    OP     THE     CHEST  105' 

It  was  mentioned  by  Hippocrates  and  is  called  "Digiti  Hippo- 
cratici. ' '    Trousseau  describes  it  as  follows : 

"The  deformity  consists  in  a  contraction  of  the  ungual  phalanx 
with  enlargement  and  thickening  of  the  digital  pulp.  While  the  nail 
curves  towards  the  palm,  the  extremity  of  the  finger  assumes  the  form 
of  the  large  end  of  a  club  and  sometimes  in  enlarging  it  flattens  so 
as  to  resemble  the  head  of  a  serpent.  This  deformitj^  generally  comes 
on  by  slow  degrees  but  at  other  times  it  is  produced  with  great  rapid- 
ity, the  patient  suffering  pain  during  the  process.  In  some  persons- 
the  toes  are  the  seat  of  a  similar  deformit.y,  but  when  it  occurs  in  the 
toes  it  is  generally  in  a  much  less  degree  than  in  the  fingers. ' ' 

Trousseau  does  not  mention  the  change  as  affecting  the  nose,  but 
other  writers  call  attention  to  this  fact,  and  I  have  seen  it  occasionally. 
It  has  also  been  stated  that  in  the  digital  affection  the  nail  is  raised 
from  its  bed  and  that  by  bearing  down  on  its  proximal  end,  the  hard, 
elevated  margin  of  the  root  of  the  nail  may  be  felt.  While  in  most 
cases  this  is  true,  and  the  stretched,  shining  atrophic  skin  over  the 
root  indicates  the  hyperplasia  beneath,  yet,  quite  frequently  in  my  ex- 
perience, the  nail  has  been  sunken  and  the  hyperplasia  seemed  to  sur- 
round it  as  a  wall.  Particularly  is  this  the  case  in  the  flat  clubbing,, 
likened  by  Trousseau  to  the  head  of  a  serpent.  The  enlarged  digits 
often  show  e.yanosis.  The  disease  is  general  and  bi-lateral  although  all 
fingers  are  not  equally  affected.  In  a  recently  reported  case  of  sub- 
clavian aneurysm  it  occurred  only  upon  one  side.  It  has  been  known 
to  appear  and  disappear  without  any  known  disease  being  associated. 
Its  progress  is  generally  slow  but  it  may  attain  considerable  propor- 
tions in  two  or  three  weeks.  In  the  order  of  the  frequency  of  its  asso- 
ciation it  occurs  in  bronchiectasis,  chronic  pulmonary  tuberculosis, 
especially  in  conjunction  with  cavity,  emphysema,  chronic  bronchitis, 
chronic  asthma,  empyema,  congenital  heart  affections  accompanied  by 
cyanosis,  and  certain  valvular  lesions.  In  the  first  mentioned,  its  oc- 
currence is  so  frequent  as  to  be  of  some  diagnostic  value  and  is  apt  to 
be  associated  with  changes  in  the  nose  and  toes.  In  mitral  insuffi- 
ciency it  occurs  especially  when  a  child  is  the  sub.ject  of  the  attack. 
Its  association  with  pulmonary  tuberculosis  is  well-illustrated  in  dis- 
pensary practice. 


SECTION  V. 

BRONCHITIS. 

De/iitilioit.  vVn  acute  or  chronii,'  iuflaniniatioii  ol'  tlir  bronrliial 
tubes  oeeiiiTiug  jiriniai-ily  m-  in  the  course  of  various  diseases.  When 
the  finest  ramifieatious  of  tlic  bronchi  are  the  seat  of  the  disease  it 
is  called  capillary  bronchitis. 

ACUTE  BROXCHITIS. 

Inspecliun  shows  only  slifiht  increase  in  the  number  of  n's|)ira- 
tions,  which  occurs  in  the  febrile  .stage  of  the  acute  attack.  The  res- 
pirations have  a  somewhat  hurried  character. 

Palpation.  Vocal  fremitus  normal.  Occasionally  a  distinct  liion- 
•ehial  fremitus  is  transmitted  to  the  chest  surface. 

Percvssion.  The  resonance  is  clear  over  the  entire  area,  ll  may 
be  slightly  diminished  in  the  lower  and  posterior  regions  when  larue 
amounts  of  mueus  have  accumulated  in  the  bronchial  tubes. 

Auscultatio)).  The  respiratory  murmur  changes,  becoming  more 
bronchial  and  harsher  in  character.  Expiration  is  usually  quite  no- 
ticeable, which  is  not  generally  the  case  in  health.  New  sounds  are 
present,  called  rales.  These  may  at  first  be  dry  and  afterwards  be- 
■eome  moist,  more  usually  both  exist  at  the  same  time  and  are  heard 
in  different  areas.  Sometimes  they  are  so  harsh  in  character  and  so 
widely  dift'used  as  to  mask  the  breathing  sounds.  The  larger  tubes 
give  rise  to  large  bubbling  or  sonorous  rales,  the  finer  ones  to  small, 
hissing  or  sibilant  rales.  In  a  very  few  cases,  accompanied  by  an 
•extremely  viscid  exudate,  there  may  be  some  fremitus.  In  these  cases 
the  respiration  may  be  bi-oneho-vesicular  and  the  symptoms  mislead- 
ing.   Ordinarily  the  vocal  resonance  is  normal. 

The  cardinal  symptoms  of  acute  bronchitis  are  cough,  expectora- 
tion and  dyspu(pa.  although  children  below  the  age  of  five  years  do 
not  expectorate,  and  the  dyspncea  caused  by  a  slight  catarrhal  intiam- 
mation  of  the  smaller  tubes  may  be  inappreciable. 

The  disease  generally  begins  as  a  catarrh  of  the  nasal,  pharyngeal 


BRONCHITIS  107 

or  laryngeal  regions,  with  hoarseness  and  tickling  in  the  throat,  soon 
succeeded  by  a  sense  of  rawness  behind  the  sternum,  and  in  severer 
cases,  or  in  emphysematous  subjects  a  sense  of  tightness  in  the  chest. 

The  principal  characteristics  of  the  disease  are  that  it  is  bilateral, 
that  percussion  and  voice  sounds  are  normal,  that  the  adventi- 
tious soimds  change  in  character  and  location  with  great  rapidity, 
that  it  is  accompanied  by  a  cough  that  is  at  first  short,  dry,  hacking, 
painful  and  which  recurs  in  severe  paroxysms.  When  the  hyperasmia 
of  the  bronchial  mucous  membrane  subsides  and  free  secretion  inter- 
venes the  cough  loses  these  characteristics  and  becomes  loose  and  pain- 
less, but  is  still  paroxysmal. 

The  sputum  of  bronchitis  is  at  first  scanty,  viscid  and  tenacious, 
■expelled  with  much  difficulty  and  adheres  to  the  vessel.  It  may  be 
blood-streaked.  Later  it  is  more  mixed  with  saliva,  less  viscid,  is 
frothy  from  admixed  air  and  resembles  partially-beaten  white  of  egg. 
It  is  now  scantily  mixed  with  leucocytes.  In  the  third  stage  it  con- 
sists largely  of  an  admixture  of  leucocj^tes  and  mucus,  becomes  again 
■denser,  its  color  changed  to  yellow  or  dirty  green  and  the  separate 
mouthfuls  do  not  agglutinate.  The  amount  may  be  eight  to  ten  ounces 
in  twenty-four  hoiirs.  The  microscope  shows  mucous  corpuscles  and 
■epithelium  floating  in  clear  fluid.  The  epithelium  is  cylindrical  and 
•ciliated.  In  the  second  stage  hyaline  cells,  leucocytes,  epithelium,  oil 
globules  and  a  few  blood  corpuscles  may  be  observed.  Pulmonary 
phthisis  is  the  only  disease  that  resembles  bronchitis  in  any  of  its 
physical  signs,  but  the  course  of  the  disease  and  the  absence  of  tubercle 
bacilli,  soon  clear  up  the  doubt. 

Capillary  Bronchitis.  On  inspection  no  difl:'erences  from  the 
above  signs  are  noted,  but  in  advanced  cases  marked  lividity  due  to 
lack  of  blood  aeration  is  present. 

Mensuration,  no  change. 

Percussion.     Note  normal  or  slightly  exaggerated. 

Vocal  resonance  normal. 

Auscultation.  Vesicular  murmiu*  is  weakened  and  in  some  eases 
■suppressed.  Subcrepitant  rales  are  heard  on  both  sides  of  the  chest. 
If  heard  over  considerable  areas  they  indicate  positive  and  extensive 
inflammation  of  the  capillary  tubes.  These  fine  rales  may  be  heard 
•only  in  the  dependent  and  posterior  portions  of  the  lung,  in  which 
■ease  they  are  due  to  the  gravitation  of  fluid  from  the  larger  into  the 


108  BROXCIIITIS 

smaller  tubes.     Above  ihesf  areas  tiie  hu'ire  moist  rales  may  be  abund- 
ant or  mixed  with  liner  ones. 

Diffcroitial  Diai/uosi.s.  This  disease  miizlit  be  mistaktii  tor  pneu- 
monia, but  the  normal  or  exaggei-ated  percussion  resonanee.  its  bilat- 
eral character  with  snberepitant  rales  heard  on  both  sides,  and  the 
absence  of  bronchial  breathing:,  should  set  the  [ihysieian  ri,uht.  The 
disease  attacks  the  aired  and  younsj  children.  While  clinically  it  is 
distinguished  from  catarrhal  pneumonia,  in  practice  it  is  often  im- 
possible to  determine  which  disease  has  attacked  the  patient. 
CHRONIC  BRONCHITIS. 

Presents  no  distinctive  features,  except  in  cases  due  to  mechanical 
irritation,  the  so-caHed  artisan's  bronchitis.  This  type  may  be 
accompanied  b>-  wasting,  due  to  induration  of  the  lung.  tli\is  resem- 
bling phthisis,  but  diti'ers  from  it  in  its  essential  chrdiiicitN-  and  the 
absence  of  tubercle  bacilli 

e:\ipiiysema. 

Definition.  A  chronie  interstitial  inflammation  nl'  tln^  lungs, 
causing  obliteration  of  the  capillaries,  associated  with  dilatation  of 
the  air  spaces. 

A  compensatory  emphysma  is  recognized  when  one  lung,  or  a 
portion  thereof,  by  reason  of  di.sease  being  unable  to  perform  its  func- 
tions the  remainder  increases  in  bulk  and  the  air  spaces  dilate.  This 
condition  is  not.  however,  pathologic. 

Physical  Signs.  Inspection.  The  patient  is  cyanotic,  especially 
after  exertion.  The  bi'eathing  is  rapid.  In  advanced  cases  the  upper 
part  of  the  thorax  is  dilated  and  prominent,  especially  the  .sternum 
aud  clavicles.  The  muscles  of  respiration  and  the  elevators  of  the 
che.st  are  hypertrophied,  especially  the  scaleui  and  the  .sterno-cleido- 
mastoids.  If  both  lungs  are  atfected  the  chest  is  barrel-shaped,  the 
spinal  column  bent  forward,  the  shoulders  rounded  so  that  the  patient 
seems  to  stoop.  The  middle  and  sometimes  the  upper  interco.stal 
spaces  are  widened,  the  lower  ones  narrowed,  and  the  lower  ribs  drawn 
in.    The  above  picture  depicts  the  hypertrophic  type  of  the  disease. 

There  is,  however,  a  form  of  the  disease  in  which  the  lungs  are 
atrophied  instead  of  hypei'trophied,  but  in  which  the  symptoms  do 
not  radically  differ  from  those  of  the  above  type.  Atrophic  em- 
physema is  generally  found  in  the  aged,  and  may  be  looked  upon  as. 
a  part  of  the  physiologic  process  of  decay. 


BROXCHITIS  109 

The  chest  movements  are  altered.  Instead  of  the  rhj^hmical  ex- 
pansion and  contraction  seen  in  normal  respiration,  the  chest  is  lifted 
as  thongli  it  were  an  inflexible  piece,  and,  owing  to  calcification  this 
is  indeed  often  the  case.  The  lower  ribs  and  abdominal  muscles  are 
drawn  in  with  inspiration,  the  breatlring  is  labored  and  of  the  abdom- 
inal type :  the  diaphragm  being  brought  little  into  action. 

Palpation.  Fremitus  varies,  sometimes  it  is  increased,  at  others 
diminished.  The  apex  beat  is  generally  lowered  and  pushed  to  the 
right. 

Eadioscopy  shows  that  in  emphysema  the  diaphragm  occupies  a 
lower  plane  and  does  no't  rise  during  expiration  to  the  normal  level, 
and  that  the  heart  assiimes  a  much  more  vertical  position  in  this  disease 
than  it  occupies  in  the  healthy  chest. 

MciisuraiioH.  Both  the  circumference  of  the  chest  and  the  antero- 
posterior diameter  are  increased.  The  antero-posterior  diameter  often 
equals  the  transverse. 

Percussion.  The  percussion  note  is  clear  and  ringing,  the  pitch 
being  lowered  but  the  intensity  of  the  sound  increased.  It  is  in  this 
disea.se  that  we  get  the  typical  vesiculo-t^'mpanitic  note.  The  note  is 
not  changed  either  by  forced  inspiration  or  forced  expiration.  The 
finger  feels  increased  resistance.  The  area  of  cardiac  dullness  may  be 
absent.  Although  there  is  very  generally  present  hypertrophy  of  the 
right  ventricle,  it  cannot  be  demonstrated  during  life. 

Auscultation.  The  inspiratory  sound  is  .short,  feeble  and  even 
suppressed.  Expiration  is  greatly  prolonged  and  may  be  three  or  four 
times  as  long  as  inspiration.  The  pitch  of  both  is  lowered.  Rales 
of  all  sizes  and  qualities  may  be  heard.  In  those  eases  where  narrow- 
ing of  the  bronchi  has  resulted  from  chronic  inflammation,  both  in- 
spiration and  expiration  are  prolonged,  nearer  equal  in  length,  harsh, 
sibilant,  high-pitched  and  may  be  accompanied  by  rales,  especially  if, 
as  is  usually  the  ease,  bronchitis  coexists.  Theoretically,  vocal  reso- 
nance should  be  alwaj-s  diminished,  owing  to  the  lessened  "sdbration 
in  the  air  columns.  As  a  matter  of  fact  it  varies  as  does  fremitus,  be- 
ing occasionally  normal  or  even  increased  without  any  satisfactory 
reason  being  evident. 

Differcniiial  Diagnosis.  Emphysema  might  be  mistaken  for  pneu- 
mothorax or  pleural  eft'usion.  From  the  first  it  differs  in  that  the  per- 
cussion sound  is  always  pulmonic,  even  if  tjTnpanitie,  and  the  breath- 
ing is  still  vesicular,  while  in  pneumothorax  both  are  amphoric.     Em- 


110  BRONCHITIS 

physeina  is  bilateral,  ])iieiiniotliorax  is  unilateral  and  iiietallie  tinkling- 
is  diagnostic  Percussion  dullness  over  effusion  contrasts  strongly 
with  the  vesiculo-tympanitie  note  of  emphysema.  The  mahidy  is  most 
fi-equently  the  seqiiel  to  bronchitis. 

Iltemoptysis,  although  a  rare' occurrence  in  emphyseniM,  ina>-  laUe 
place  and  has  been  known  to  prove  fatal.  In  fatal  eases  il  is  prol)- 
ably  dne  to  rupture  of  the  aorta,  since  extensive  atheroma  of  this  ves- 
sel occurs  in  the  disease.  The  ordinai-y  hjemoptysis  of  emiihysema  is 
small  and  unimportant. 

SPASMODIC  OR  HROXClllAL  ASTHMA. 

Dcfimiion.  A  spasmodic,  ]iaroxysinal  panting  for  breath  due  to 
contraction  of  the  caliber  nf  tiu'  hmiicliial  tulies.  The  seizures  are 
probably  of  nervous  origin. 

Physical  Signs.  Inspection.  Breathing  is  labored,  the  muscles 
of  respiration  stand  out  prominently,  the  abdominal  muscles  are  con- 
tracted and  hard.  Inspiration  is  prolonged  and  labored,  as  is  also  ex- 
piration. The  patient  sits  up,  leans  forward  and  grasps  some  object 
to  aid  in  the  fixation  of  the  shoulder  muscles.  The  face  is  cyanotic, 
the  expression  anxious.  The  chest  is  in  a  permanent  state  of  intla- 
tiou,  hence  shows  little  expansion  with  inspiration. 

Palpation.  Rhonehial  fremitus  is  recognizable,  vocal  fremitus  is 
lessened  and  often  covered  by  the  rhonchi. 

Percussion  is  unchanged  in  true  asthma.  In  associated  emphy- 
sema it  is  exaggerated. 

Auscultation.  The  rhythm  of  the  respiratory  nnirnuH'  is  jerky 
and  irregular,  now  exaggerated,  now  suppressed.  The  vesieulai-  mur- 
mur is  inaudible  owing  to  lessened  vesicular  interchange.  All  over 
the  chest  are  heard  sonorous  and  sibilant  rales  with  both  inspiration 
and  expiration,  and  expiration  is  noticeably  prolonged.  The  dry 
rales  change  to  moist  as  the  attack  progresses  and  the  change  brings 
relief. 

Differential  Diagnosis.  There  are  attacks  of  renal  asthma 
which  closely  resemble  the  above  form,  but  in  these  the  dyspnoea  is 
less  marked,  and  the  kidney  lesions  are  manifest  on  examination  of 
the  urine.  Rhonchi  and  rhonehial  fremitus  are  less  pronounced  and 
may  be  absent,  but  the  expiratory  character  of  the  dyspnoea  is  apparent 
in  both  forms.    Spasm  or  paralysis  of  the  glottis  produces  a  dyspnoea 


BROKCHITIS 


111 


which  resembles  asthma,  but  in  these  the  difficulty  is  wholly  inspira- 
tory and  the  rales  are  not  present. 

BRONCHIECTASIS. 

Definition.  An  acute  or  chronic  affection  characterized  by  dilata- 
tion of  the  bronchial  tubes,  cough  and  characteristic  expectoration. 
The  dilatations  may  be  cylindrical  or  sacculated.  In  the  acute  cases 
the  former  are  generally  found,  while  in  the  chronic  cas6s  the  sacs  are 
gradually  formed.  Occasionally  the  acute  cases  give  rise  to  saccida- 
tions.  There  is  also  an  acute  and  chronic  form  of  enlargement  of  the 
bronchioles  (bronchiolitis)  but  the  physical  signs  are  not  sufficiently 
distinctive  to  allow  the  disease  to  be  described  apart  from  bronchiecta- 


Fig.    32 — Curschman's    Spirals.     A    Natural    size.      B    Enlarged. 

sis.     This  latter  form  follows  acute    infectious     diseases,     especially 
measles  and  whooping  cough.    It  may  become  chronic. 
Clinically  we  recognize  three  forms  of  the  disease : 

(a)  Pure  bronchiectasis  which  follows  after  bronchitis,  espe- 
cially chronic  bronchitis,  pneumonia,  pleurisj-,  empyema.  Its  associa- 
tion with  the  first  is  well  kno'ATi,  but  it  is  also  especially  prone  to  be 
present  in  lobar  or  broncho-pneumonia,  where  it  is  limited  to  the 
bronchi  within  the  affected  area.  Influenza  is  responsible  for  not  a 
few  cases,  and  bronchiectasis  which  may  be  classified  as  acute,  has  suc- 
ceeded its  attacks. 

(b)  Tiiberculous  bronchiectasis.  Few  cases  of  pulmonary  tuber- 
culosis progress  to  the  end-  without  the  formation  of  bronchiectasis. 
Sometimes  the  large  cavities  so  formed  are  mistaken  for  vomicae.     In 


11L>  BKOXCIIITIS 

oiu'  of  my  cases  enorinoiis  dilatations  were  present  in  a  huiL:  riililled 
with  tuberculous  cavities. 

Both  the  sacfular  dilatations  and  the  rxlintli'ieal  enlariivnients  are 
found. 

(e)  Trautiuilic  bronchiectasis,  caused  by  the  pressure  of  a  for- 
eign body  within  the  bronchi  or  external  pressure  exerted  on  a  bron- 
chus, causinir  kinking  or  stenosis  of  the  tube  and  subsequent  dibit a- 
tion. 

In  the  three  forms  enumerated  the  disease  is  essentially  chronic, 
cases  sometimes  lasting  ten  to  twenty  years.  A  ease  seen  by  me  began 
with  pneumonia  which  was  followed  by  empyema  and  then  by  bron- 
chiectasis. 

The  physical  signs  vary  with  the  location,  size  of  the  .sac  and  the 
amount  of  its  contents,  giving  rise  to  wholly  different  signs  when  full, 
partly  full  or  empty.  The  sacculated  cases  are  unilateral.  The  cavi- 
ties most  often  form  in  the  lower  lobe.  They  are  rarely  single,  some- 
times two  communicate  by  a  narrow  passageway.  Oft  times  there  are 
two  large  ones  and  one  or  two  of  lesser  size.  The  size  of  the  dilatations 
varies  greatly. 

Inspection  sliows  deficient  expansion  over  the  atl'eeted  area. 
Breathing  is  labored,  expiration  prolonged.  The  expression  is  anxious, 
varying  degrees  of  cyanosis  are  not  uncommon.  In  chnmic  eases 
the  fingers  are  clubbed,  the  nails  incurved.  In  cases  following  chronic 
lung  diseases,  especially  an  old  empj-ema.  a  pneiunonia,  or  a  pleu- 
risy where,  as  is  so  often  the  case,  adhesions  have  followed,  the  re- 
tracted side,  the  compensatory  bulging  opposite  to  it,  the  shoulder 
droop  on  the  affected  side,  and  the  forward  curve  of  the  spine  form 
a  most  impressive  image.  If  upon  these  is  engrafted,  as  is  occasionally 
the  case,  a  hyperostosis  of  the  extremities,  hands,  fore-arms,  feet  and 
legs,  the  picture  is  inett'aceable.  This  proliferating  hypero.stosis,  de- 
scribed by  Marie  and  named  osteo-arthropathie  pneumique,  occurs  in 
other  chronic  lung  diseases,  and  differs  from  acromegaly  in  that  it 
.affects  only  the  parts  mentioned  and  is  a  true  proliferation. 

Palpation.  Vocal  fremitus  is  usually  increased  by  reason  of  the 
associated  induration  resulting  from  the  causative  disease,  such  as 
broncho-pneumonia.  Rhonchial  fremitus  is  also  present.  The  fremi- 
tus may  not  be  manifest  unless  the  voice  is  considerably  raised. 

Percussion.  There  is  very  generally  a  considerable  area  of  dull 
percussion  resonance,  even  of  flatness,  in  the  region  affected,  which  is 


BRONCHITIS  113 

more  often  the  lower  lobes.  Dullness  will  be  found  posteriorly  and 
laterally  oftener  than  anteriorly. 

With  a  full  sac  surrounded  by  induration  flatness  prevails.  With 
a  large,  completely  empty  sac  the  note  is  tympanitic.  With  smaller 
sacs  and  with  cylindrical  enlargements  the  note  is  tubular. 

Ausmdtaiion.  The  breath  sounds  are  absent  with  a  full  sac.  They 
are  bronchial,  cavernous  or  amphoric  when  the  sac  is  empty.  When 
half-full  splashiugs,  suecussions  and  bubblings  are  heard  with  both 
inspiration  and  expiration.  With  an  empty  sac,  bronchophony  and 
pectoriloquy  may  be  heard. 

When  the  cavities  are  full  breathing  may  be  deficient  over  the  en- 
tire affected  half  of  the  thorax,  but  is  subject  to  rapid  changes.  A 
full  inspiration,  a  cough  or  even  a  change  of  position  renders  it 
audible. 

Bales.  Extensive  rales  are  heard  parJout,  large,  loud,  sonorous, 
gurgling,  mucous,  rapidly  changing.  They  are  especially  manifest 
and  characteristic  when  the  ca'S'ity  is  partially  filled. 

Cough.  The  patient  may  have  considerable  intervals  of  freedom 
from  cough,  days  or  weeks.  This  and  the  character  of  the  cough  ren- 
der it  distinctive.  It  is  always  paroxysmal,  usually  matinal,  the  pa- 
tient generally  having  a  premonition  of  its  oncoming.  Each  paroxysm 
may  exhibit  a  descending  scale  both  as  to  the  intensity  and 
the  force  of  the  succeeding  notes.  Thus,  a  single  paroxysm  may  con- 
sist of  six  notes,  the  first  loud,  hard,  expulsive,  with  each  successive 
note  a  little  less  intense  than  its  predecessor.  After  a  brief  pause  a 
repetition  of  the  effort  occurs,  until  with  some  chokings  and  gaspings, 
the  cavity  is  emptied. 

Sputa.  This  varies  in  amount  with  the  size  of  the  cavity  and  the 
frequency  with  which  it  is  emptied.  Four  drams  to  half-a-cupful  is 
an  ordinary  amount.  Its  color  varies;  white,  gray,  yellow,  green, 
brown.  It  is  exceedingly  offensive,  the  odor  being  foetid  or  cheesy, 
"as  of  the  ripe  Camembert  cheese. 

When  placed  in  a  tall  glass  the  sputum  separates  into  three  lay- 
ers. An  upper,  frothy  layer  which  may  be  colored,  a  middle  layer  of 
watery  mucoid  fluid;  the  third,  a  thick  sediment  of  granular  matter, 
cells,  casts  of  the  tubes,  bacteria,  crystals  of  fatty  acids,  and,  if  ulcera- 
tion of  the  walls  be  present,  elastic  fibers  are  found.  Sections  of  the 
casts  show  peculiar  alternate  layers  of  inspissated  secretion  and  bac- 


114  UHnNCIllTIS 

teria.  In  no  disease  is  Xhc  sputniii  more  eliarauteristit;,  ami  its  apiK'ar- 
auee  to  the  uaked  eye  is  sufficieut  to  establish  the  diagnosis. 

Bacleria.  The  iutivienza  bacillus  in  pure  cultures  has  been  t'ound 
present  so  frequently  in  these  cases  as  to  raise  the  question  of  its 
causative  relation.  Lord,  of  Boston,  relates  thirty-five  cases  of  bron- 
chitis and  bronchiectasis  in  which  it  was  found,  and  other  observers 
have  met  with  it  almost  as  frequently,  but  the  ubiquitousness  of  this 
germ  and  its  association  with  conditions  so  varied  and  diverse,  throw 
doubt  upon  the  relation  of  cause  and  eft'ect. 

Hcennyptysis.  Hipniorrhage  frequently  occurs  in  ihc  course  of  the 
disease  and  is  often  profuse,  due  to  the  rupture  of  small  aneurysms 
formed  within  the  dilatations,  or  to  tears  in  the  enlarged  capillaries 
and  venules. 

Differential  Diaynosis.  Tlic  rapid  changes  in  the  respiratory 
murmur,  becoming  loud  and  harsh  where  a  moment  before  it  was  in- 
audible, the  character  of  the  rales,  and  especially  the  physical  proper- 
ties of  the  sputum  and  the  absence  of  tubercle  bacilli  therefrom,  serve 
to  distinguish  the  disease  from  phthisis.  Further,  the  cavities  of 
bronchiectasis  are  usually  at  the  base,  while  the  excavations  of  phthisis 
begin  at  the  apex  of  the  lung. 

Dull  percussion  and  induration  are  signs  of  pneumonia,  with 
which  the  disease  is  not  infrequently  associated,  but  the  temporary 
character  of  the  one,  the  varied  fremitus,  the  cavernous  or  amphoric 
breathing  of  the  other,  should  prevent  the  mistake. 

Rupture  of  an  empyema  into  the  bronchus  comes  on  suddenly 
and  has  been  preceded  by  a  pleurisy.  Nevertheless  these  dilatations 
exist  with  chronic  phthisis,  pleurisy  and  empyema. 

BRONCHIAL  STENOSIS  AND  OBSTRUCTION  OF  THE  LARGE 
BRONCHI. 

Narrowing  of  a  large  bronchus  may  arise  from  a  variety  of 
causes.  Complete  obstruction  is  rarer.  The  principal  factors  caus- 
ing stenosis  are:  External  compression,  most  frequently  by  an 
aneurysm,  less  frequently  by  other  media.stinal  growths;  syphilitic 
disease;  cicatrization  following  ulceration  and  constriction:  oblitera- 
tion by  a  foreign  body. 

Complete  obstruction  i.s  followed  by  collapse  of  the  part  of  the 
lung  supplied  by  the  tube.  In  time,  compensatory  changes  take  place 
in  other  portions  of  the  affected  lung  and  in  its  fellow. 


BRONCHITIS  115> 

Dyspnoea  is  the  most  characteristic  sjanptoni  and  varies  with  the' 
completeness  of  the  obstruction,  the  suddenness  of  its  production  and 
the  degree  of  compensation  which  follows.  As  said  under  aneurysm, 
this  cause  is  productive  of  the  most  intense  dyspnoea,  which  may  be 
continuous  or  paroxysmal. 

Physical  Signs  are :  Impaired  expansion  on  the  affected  side, 
which  may  be  local  or  general.  If  a  main  bronchus  is  involved,  the 
entire  side  of  the  thorax  is  affected.  The  suprasternal  and  supra- 
clavicular fossiTi  are  drawn  inwards  with  inspiration,  the  intercostal 
spaces  recede  as  does  the  epigastrium  at  the  xiphoid  angle. 

Later,  retraction  of  the  chest  walls  follows  over  the  collapsed  area. 

Palpation  shows  diminished  expansion  and  enfeebled  tactile  fre- 
mitus over  the  defective  area.  As  secondary  changes  occur  rhon- 
chial  fremitus  develops. 

Percussion.  The  note  rises  in  proportion  to  the  amount  of  col- 
lapse and  becomes  dull  in  total  obliteration.  In  old  cases  where  con- 
densation of  lung  tissue  is  followed  by  fibrous  and  pleural  thickening 
the  note  is  dull  or  flat. 

Auscultation.  The  peripheral  breath  sounds  are  feeble  or  alisent. 
-Stridor  may  be  present  and  heard  near  the  seat  of  constriction.  It 
should  be  sought  for  posteriorly  outside  of  the  vertebraj,  along  the 
inner  edge  of  the  everted  scapulae.  Vocal  resonance  is  proportionally 
diminished.  Later,  rales  develop  from  retained  secretions,  and  as 
stenosis  is  one  of  the  chief  causes  of  bronchiectasis,  signs  of  that  dis- 
ease may  follow. 

Cough  is  present  and  varies  with  the  cause  and  the  degree  of  ob- 
struction. The  sputum  has  no  especial  characteristic  unless  bronchial 
dilatation  follows,     (q.  v.) 


SECTION  VI. 

PLEURISY. 

Definition.  Pleurisy  is  au  iiitiaiimiatiou  of  one  or  both  pleural 
sacs.  Varieties.  Primary,  secondary :  Acute,  chronic :  Circum- 
scribed or  diffused:     Dry  pleurisy,  pleurisy  with  eft'usion. 

Because  this  disease  so  often  passes  unrecognized  by  the  physi- 
cian, in  spite  of  its  pronounced  physical  signs,  as  evinced  i)y  the  fact 
that  extensive  adhesions  are  often  found  post-mortem  without  any  his- 
tory of  pleurisy  being  elicited,  it  deserves  a  minute  description. 

The  various  stages  of  the  malady  present  different  signs,  and  will 
therefore  be  considered  .sepai'ately.  Inspection,  palpation,  mensura- 
tion, percussion  and  auscultation  all  give  intelligent  answers  when 
applied  as  interrogatives  to  this  disease. 

In  the  beginning  of  an  attack,  whatever  form  it  may  afterwards 
assume,  the  lesion  is  that  of  a  dry  pleurisy,  in  which  the  two  con- 
tiguous layers,  first  the  visceral  and  then  the  parietal, become  inflanied. 
Following  this  an  exudate  of  thick,  soft  gray  or  yellow  lymph  is  de- 
posited upon  the  two  surfaces,  sometimes  in  distinct  layers.  At  first 
this  lightly  adherent  lymph  may  be  easily  rubbed  off',  after  a  time  it 
is  .sticky,  rough,  shaggy  and  quite  adherent.  The  two  surfaces  may 
now  become  agglutinated  and  the  attack  thus  terminate  (Pleuritis 
sicca). 

In  the  beginning  and  at  its  height  such  a  condition  presents  the 
following  signs: 

Inspection.  Increased  frequency  of  breathing  but  with  restric- 
tion of  the  respiratory  movements.  Enfeebled  respiration  which  is 
made  manifest  by  comparison  with  the  sound  side.  The  limitations  of 
the  respiratory  excursion  vary  with  the  severity  of  the  pain. 

Palpation.  Touch  will  sometimes  reveal  a  peculiar  fremitus 
cau.sed  by  the  friction  of  the  two  surfaces  (pleural  fremitus  of  Da- 
Costa)  over  the  region  corresponding  to  the  area  of  inflammation.  Vo- 
cal fremitus  during  the  inflammatory  stage  remains  unaltered  or  is 
even  increased  ovei-  the  inflamed  area.     Absent  vocal  fremitus  is  one 


PLEURISY  117 

of  the  early  signs  of  ett'usiou.  The  reader  is  again  reminded  that  vocal 
fremitus  is  normally  more  marked  on  the  right  side  than  on  the  left. 

Mensuration.  Previous  to  the  exudate,  no  change.  (Right  side 
normally  the  larger.) 

Percussion.  Prior  to  the  effusion  percussion  elicits  little  or  no 
information. 

Auscultation.  In  the  presence  of  severe  pain  the  respiratory 
rhythm  changes  and  becomes  irregular  and  jerky.  Likewise  pain 
causes  the  respirations  to  become  shallow  or  enfeebled,  in  which  case 
the  normal  vesicular  murmur  is  diminished — thus  confirming  the  signs 
elicited  by  inspection.  Friction  sounds  are  audible  especially  on  deep 
breathing.  They  are  superficial  and  have  a  sandpaper  quality.  G-en- 
erally  they  are  heard  on  both  expiration  and  inspiration ;  sometimes 
they  are  limited  to  expiration.  They  may  be  limited  to  a  single  spot  in 
the  inframammary  or  infraaxillary  space,  and  hence  be  easily  over- 
looked. Usuallj'  the  area  is  more  extensive.  The  sound  resembles  the 
crepitant  rale,  but  this  rale  is  an  inspiratian  rale. 

PHYSICAL  SIGNS  OF  EFFUSION. 

Inspection.  With  moderate  effusions  inspection  shows  lessened 
chest  movements,  due  to  inability  of  the  lung  to  expand  to  its  full 
capacity.  Pain  may  or  may  not  be  present.  When  present  it  is  usu- 
ally accompanied  by  an  increase  in  the  number  of  the  respirations, 
which  may  even  amount  to  dyspnoea.  In  the  absence  of  pain,  respira- 
tions may  be  even  lessened  in  number.  The  interspaces  above  the 
diaphragm  may  be  widened.  A  moderate  effusion  is  one  in  which 
the  level  of  the  fluid  does  not  rise  above  the  nipple  in  front. 

Palpation  in  moderate  effusions.  Confirmation  of  signs  revealed 
by  inspection,  as  diminished  respiratory  rhythm  and  widening  of  the 
lower  interspaces.  The  friction  fremitus  will  have  disappeared.  In 
small  effusions  the  tactile  fremitus  is  generally  diminished.  This  sign 
is  more  valuable  in  men  than  in  women  and  children.  It  must  be  re- 
membered that  fremitus  is  usually  stronger  on  the  surface  of  the 
right  chest  than  on  the  left;  stronger  in  men  than  in  women. 

Mensuration  shows  little  if  any  variation  in  small  and  moderate 
effusions.  In  right-handed  individuals,  especially  men  of  the  labor- 
ing class,  the  circumference  of  the  right  chest  is  normally  greater  than 
that  of  the  opposite  side. 

Percussion.     Dullness  increasing  to  flatness  over  the  area  of  the 


118 


eftusion  is  the  most  important  siijn  of  the  exudate.  In  adults  it  is 
difficult  if  not  impossible  to  demonstrate  effusions  of  less  than  five 
hundred  cubic  centimeters.  The  dullness  is  usually  most  marked  and 
lirst  obtainable  i)Osteriorlv,  then  in  the  a.xillary  retrioii.  lastly  in  fi'ont. 


F'g-  3.? — Physical  signs  in  effusion  into  left  pleura  (Patten).  .\  Skodiai-  per- 
cussion resonance,  exaggerated  vocal  resonance,  tubular  quality  of  breath- 
ing. B  Complete  dullness,  absence  of  vocal  fremitus,  no  respiratory  sounds. 
C  Purile  respiration,  prolonged  expiration,  exaggerated  percussion  reson- 
ance. D  More  or  less  well  marked  pulsation.  F  Displaced  area  of  cardiac 
dullness.     Upper  limit  of  shading  indicates  anterior  line  of  Ellis'  curve. 

Along  the  upper  border  of  the  effusion  percussion  dullness  is  ob- 
tained and  increases  to  flatness  as  we  percuss  from  above  downward. 
Total  absence  of  vibration,  coupled   with  an   increased  sense  of  re- 


PLEUEISr  119 

sistance  under  the  pleximeter  finger,  mneh  greater  than  that  observed 
in  eases  of  lung  cousolidation.  are  most  noteworthy  and  significant 
symptoms. 

The  prevalent,  in  fact  almost  universally  accepted,  belief  that  the 
level  of  pleural  efliusions  changes  with  alterations  in  the  position  of  the 
patient  is  ahnost  wholly  erroneous,  and  is  the  probable  reason  why 
such  effusions  frequently  are  overlooked.  Only  occasionally  does  such 
change  of  level  occur,  and  I  wish  to  lay  special  stress  xipon  this  fact. 
As  pointed  out  by  Flint,  Da  Costa,  and  others  since,  we  get  in- 
creased percussion  resonance,  even  amounting  to  tympany,  above  the 
level  of  the  fluid;  This  peculiarity  is  due  to  disturbance  of  normal 
tension  in  the  pulmonary  tissue,  which  is  more  or  less  condensed.  The 
change  of  quality  is  variously  known  as  Flint's  vesicnlo-tympany, 
Skoda 's  resonance,  etc.  In  moderate  transudations  the  upper  level 
of  the  elfusion,  and  hence  of  percussion  dullness,  is  not  a  straight  line 
but  a  horizontal  curve  with  the  convexity  upwards.  The  curve  reaches 
its  greatest  height  in  the  mid-axilla,  whence  it  descends  to  the 
sternum,  where,  however,  the  level  is  higher  than  at  the  vertebra.  In 
order  to  demonstrate  this  curve  the  patient  should  be  in  the  upright 
position.  In  a  moderate  effusion  this  line  may  extend  from  the  .junc- 
tion of  the  sixth  rib  with  the  sternum,  which  point  is  one  inch  above 
the  xiphoid  .junction,  to  the  lower  border  of  the  fourth  rib  in  the  an- 
terior axillary  line,  thence  slope  gently  backwards.  This  line  of  dull- 
ness does  not  change  with  inspiration  or  expiration  but  may  change 
with  changes  of  position. 

Auscultaiion.  Moderate  effusions.  The  breath  sounds  become 
feebler  and  more  distant  as  the  amount  of  fluid  increases.  As  has 
been  stated,  the  vesicular  portions  of  the  lung  are  pressed  upon  and 
egi'ess  of  air  is  prevented,  hence  vesicular  respiration  is  absent  and 
is  replaced,  first,  by  broncho-vesicular  and  then  by  bronchial  breath- 
ing. In  children  this  occurs  very  early  and  with  comparatively  small 
effusions.  Sometimes  the  breathing  is  amphoric.  On  the  opposite  side 
the  lung  is  doing  increased  work  and  the  breath  sounds  are  therefore 
intensified  or  puerile. 

Vocal  resonance  varies.  "When  the  effusion  is  small  in  amount 
the  voice  is  still  convej-ed  via  the  chest  walls  to  the  ear.  With  in- 
creased effusion  the  voice  sounds  are  absent  over  the  liquid.  If  lis- 
tened to  at  the  upper  border  of  the  fluid,  a  peculiar  quavering  or 
bleating,  called  egophony,  may  be  heard.    It  is  not  often  present,  but 


120 


when  lu'uril  is  (li'cisivi'.  In  typiciil  foriiis  i'L:ti|ilic)iiy  is  imconimoii, 
although  nuK-h  insisted  on  by  the  older  writei-s.  liiit  it  is  by  no  means 
rai-e  to  heai"  a  enrions  nasal.  twan^-Jike  (|uality  in  the  voice,  particu- 
larly at  the  outer  anirle  of  the  scapula. 

Moderate  effusions,  while  they  compress  the  air  cells  do  nut  affect 


Fig.  34 — Displacement  of  organs  in  a  considerable  effusion  into  right  pleura 
(Patton).  A  Slight  enlargement  of  side,  with  efTacement  of  intercostal 
spaces.     B  Compressed  hmg.     C  Displaced  heart.     D  Displaced  liver. 

the  bronchi.     Beariut;-  this  fact  in  mind  aids  in  comprehending  many 
of  the  observed  phenomena. 

LARGE  EFFUSIONS. 

In.ipectioii.      The  I'cspiratory  movements  are  much  diminished  or 

entirely  absent  on  the  affected  side,  and  increased  on  the  sound  side. 

The  intercostal  spaces  are  widened,  especially  in  the  lower  segment. 

Even   bulfriu"-  may  be  noted.     The   affected   side  looks   inflated,   the 


PLATE  IV 


Point  where  Pericardial  Friction  is  most  often  heard.  PL.F. 
Point  where  Pleuritic  Friction  is  most  apt  to  be  heard.  The 
Inner  Circle  represents  the  most  frequently  affected  Dorsal 
Area. 


PLEURISY  121 

scapula  stands  out  more  prominently  than  its  fellow,  the  shoulder  is 
elevated. 

The  heart  impulse  is  moved  to  the  left  in  right-sided  pleurisies 
and  is  foimd  outside  the  nipple  line.  It  is  sometimes  elevated  slightly. 
In  left-sided  pleurisies  the  apparent  displacement  is  much  greater, 
and  the  apex  impact  may  be  found  a  considerable  distance  to  the  right 
of  the  sternum,  even  in  the  right  nipple  line. 

Palpation  in  large  effusions  confirms  inspection  as  to  lessened 
movement  on  breathing,  widening  of  the  interspaces  and  abnormal 
position  of  the  apex.  The  impact  of  the  heart  apex  in  disease,  as  in 
health,  often  may  be  felt  when  it  cannot  be  seen.  Tactile  fremitus 
is  absent  over  large  infusions,  but  in  children  even  with  a  consider- 
able transudate,  both  vocal  and  tactile  fremitus  may  be  present,  a 
point  not  to  be  forgotten.  In  these  cases  the  sound  probably  reaches 
the  ear  through  the  medium  of  the  chest  wall. 

Mensuration.  The  affected  side  is  larger  than  the  sound  side. 
The  difference  seldom  exceeds  an  inch  or  an  inch-and-a-half .  A  cyrto- 
meter  tracing  of  the  two  sides  shows  marked  differences  in  the  con- 
tour. 

Percussion.  As  the  level  of  the  tiuid  rises  it  is  followed  by  the 
dull  percussion  note,  which  changes  to  flatness  from  above  downward. 
Flatness  is  generally  first  demonstrable  posteriorly  at  the  base  of  the 
hing.  Resistance  under  the  finger  and  absence  of  communicated  vibra- 
tions which  only  occurs  in  the  presence  of  confined  fluids  in  the 
chest,  are  signs  whose  value  have  been  previously  emphasized.  Except 
in  eft'usions  which  absolutely  compress  (carnify)  the  limg,  tympanitic 
resonance  may  be  obtained  in  front,  beneath  the  clavicle  and  above 
the  spine  of  the  scapula  posteriorly.  The  cracked-pot  sound  may  be 
elicited  by  percussion  below  the  clavicle,  while  the  patient  expires  with 
the  mouth  held  open.  Below  the  fluid  level  absolute  flatness  extend- 
ing to  points  lower  than  the  normal  limits  of  the  lung  is  present. 

Auscultation.  Vocal  fremitus  is  absent,  but  Baecelli  has  noted 
that  the  whispered  voice  sometimes  may  be  transmitted  to  the  ear 
when  the  spoken  sounds  are  inaudible.  He  states  that  this  is  not  the 
case  if  the  fluid  be  purulent,  hence  this  sign,  if  present,  denotes  serous 
effusion.  If  the  eft'usion  is  sufficiently  large  to  squeeze  the  lung  up- 
ward and  backward  into  the  spinal  gi;tter,  then  the  breath  soiinds 
wholly  disappear.  Usiially,  however,  some  breath  sounds,  feeble  and 
distant,  but  of  a  bronchial  character,  may  still  be  heard  over  the  spinal 


122  PLEURISY 

giittei-  when  the  patient  folds  the  arms  tiglitly  over  the  ehest,  so  as 
to  widely  separate  the  seapuhe.  Bronehophony  is  henrd  in  tlie  same 
region. 

Sometimes  auscultation  will  enable  us  lo  locate  tlu'  apex  of  the 


F'g-  35 — Physical  signs  (posterior  regions)  in  effusion  into  left  pleura  (Fatten). 
A  Diminished  respiratory  sounds.  B  Very  faint  or  absent  voice  sounds,  ab- 
sent breath  sounds,  dullness,  no  vocal  fremitus.  C  Dullness,  no  vocal 
fremiitus,  no  voice  or  respiratory  sounds.  D  Voice  sound  is  tubular  or 
nasal  in  quality,  sometimes  approaching  aegophony.  Upper  limit  of  light 
shading  indicates  the  posterior  line  of  Ellis'  curve. 


heart  when  it  can  neither  be  seen  no'  felt.     On  the  opposite  side  tlie 
respiratory  sounds  are  exaggerated. 

Absorption  Stacjc.    Inspection  shows  that  the  enlargement  of  the 
affected  side  is  disappearing,  that  the  widening  interspaces  are  re- 


PLELTtlSY  123 

turning  to  their  normal  condition.    -The  absent  respiratory  movements 
return,  and  the  obsciu'ed  apex  may  now  be  seen. 

Unfortunately  the  process  does  not  generally  stop  here,  but  con- 
tinues by  reason  of  contractions  and  adhesions  tmtii  various  deformi- 
ties plainly  show  the  ravages  of  the  disease.  The  organs  may  be  per- 
manently displaced.  Owing  to  adhesions  the  slow  contraction  of  the 
connective  tissue  thus  formed,  and  the  organization  of  the  exudate, 
the  resulting  deformity  appeal's  gradually,  after  a  considerable  in- 
terval, and  is  progressive.  In  ehildi-en  it  may  entirely  disappear 
with  gro^vth.  In  adults  it  is  permanent  and  varies  from  a  hollow  de- 
pression in  the  ensiform  region  to  ant«ro-posterior  flattening  of  the 
chest,  flattening  and  retraction  of  its  lateral  areas,  the  lower  ribs  be- 
ing in  contact  or  overlapping,  and  spinal  em-vature  of  greater  or 
less  degree. 

Palpation  shows  a  gradual  return  of  fremitus,  vocal  and  pleiu-al. 
.and  a  return  of  the  organs  to  their  normal  position. 

Percussion.  The  return  of  normal  percussion  resonance  is  grad- 
ual, returning  first  above  and  extending  downward.  At  the  base  reso- 
nance may  remain  permanently  absent  owing  to  accumulations  of 
solidified  plastic  material  or  to  solidification  of  lung  tissue. 

Auscultation.  Respiratory  sounds  return.  At  first  they  are  weak 
and  distant  bat  increase  in  distinctness  until  they  have  even  a  harsh 
quality.  With  disappearance  of  the  effusion,  a  return  of  the  friction 
•sound  is  noted.  At  the  base  of  the  lung  aU  sounds  may  be  feeble  and 
obscured  for  a  long  time.  As  the  vesicles  gradually  distend  a  peculiar 
creaking  or  crackling  sound  is  heard.  Bronchophony  reappears  and 
in  some  cases  egophony. 

In  cases  where  a  portion  of  the  lung  remains  permanently  imper- 
vious, there  is  permanent  loss  of  respiratory  motion  and  of  vocal  and 
respiratory  sounds  over  stich  areas. 

DIAGNOSIS. 

As  said  in  the  beginning  of  the  section,  pleiu-isj"  passes  unrec- 
ognized perhaps  oftener  than  any  other  disease  occurring  within  the 
thorax.  In  the  early  stage  the  friction  sounds  may  be  absent  and 
this  absence  is  one  of  the  chief  misleading  factors.  The  disease  is  not 
to  be  mistaken  in  the  first  stage  for  pleurodjTiia  or  intercostal  neural- 
gia. Both  of  these  disorders  are  unattended  with  pjTexia,  the  ten- 
derness is  superficial  and  excited  by  irritation  of  the  skin.  Pain  in 
pleui'isy  is  deeper-seated.     The  pain  of  pleurisy  may  however  be  re- 


rj4 


tVnvd  III  |>oinls  distant  rroiii  the  scat  nl'  the  lesioii.  'I'Ims,  llic  scvtMilli, 
eighth,  ninth,  tenth  and  eleventh  tiioraeic  uei-ves  after  passing  thi-ongh 
the  intercostal  muscles  at  the  side  of  the  thorax,  so  as  to  lie  against 
the  pleural  sac,  afterwards  pass  between  the  obliciuns  internus  and 
trausversalis  muscles  and  ultimately  reach  the  skin  of  the  anterior 
abdominal  wall.  Hence  the  frecpieney  with  which  pain  is  referred  to 
these  terminals,  a  fact  which  should  be  borne  in  mind,  and  an  examina- 
tion made  along  the  entire  course  of  the  nerves  seemingly  involved. 
In  double  pleurisy  the  pain  is  referred  to  symmetrical  points  on  I  lie 
thorax  or  abdomen,  but  in  general  synnnetrieal  pains  are  more  prob- 
able indications  of  spinal  disease.  The  pleural  friction  sound  is  gen- 
erally audible  with  the  beginning  of  expansion,  ditVei'ing  in  this  iv- 
speet  from  the  fine  crepitant  nlles  of  pneumonia. 

Left-sided  pleurisy  may  be  mistaken  for  pericardial  effusion  and 
vice  versa.  In  addition  to  the  description  given  under  pericarditis, 
the  following  points  should  aid  in  Ihe  diffei-entiation  : 


Pericarditis. 
Apex  impact  usually  cannot  be 
seen  nor  felt.     Heart  sounds  fee- 
ble and  distant. 


Dullness  extends  ui)ward  in 
pear-.shaped  area. 

Vocal  fremitus  present.  Tubn- 
lar  breathing  when  great  com- 
pression of  the  lung. 

Orthopnoea.  Faint  cyanosis  of 
face  and  extremities. 

Rotch  's  sign,  absence  of  reso- 
nance in  I'ight  fifth  intercostal 
space. 


Left-Sided  I'lr urisy. 

Heart  apex  is  displaced  to 
right.  If  much  displaced,  prob- 
ability of  efi'usion  is  increased.  If 
not  displaced  efliusion  is  improb- 
able. Apex  impact  visible  but 
displaced.  Sounds  not  changed 
in  intensity. 

Dullness  follows  around  the 
axilla  in  usual  line. 

Vocal  fremitus  absent.  Breath- 
ing sounds  absent;  if  tubular, 
strongly  marked. 

No  cyanosis,  no  orthopurea. 

Rotch 's  sign  absent. 


location  of  the 


friction   sound,   its 
diastole  of 


In  the  i)re-exudate  stage  th 
supei'ficial  character  and  its  relation  to  the  systole  aiK 
the  heart,  difl:'erentiate  the  two  conditions. 

The  effusion  may  he  mistaken  for  pulmonary  consolidation,  either 


PLEURISY  125 

•of  pneumonia  or  tuberculosis.  It  is  possible  also  to  confound  cancer 
of  the  lung  and  various  enlargements  of  the  spleen  with  the  effusion 
of  pleurisy.  From  pneumonia  and  tuberculosis  it  is  distinguished 
by  the  increase  in  size  of  the  affected  side,  widening  ,of  the  intercostal 
spaces,  absence  of  vocal  resonance  and  of  fremitus.  In  the  former  dis- 
ease the  percussion  sound  is  dull,  in  pleurisy  it  is  flat,  and  in  neither 
of  the  former  does  the  dullness  follow  Ellis's  curve.  The  bronchial 
breathing  of  a  lung  partially  compressed  by  pleural  effusion  is  much 
deeper-seated,  more  diffused  and  usually  unaccompanied  by  rales. 
In  pulmonary  tuberculosis  the  disease  generally  progresses  from  above 
downward,  while  in  pleurisy,  as  pointed  out,  the  reverse  obtains. 
Pleurisy  is  unilateral.  Tuberculosis  sufficiently  extensive  to  simulate 
it  would  be  bi-lateral.     The  history  further  aids  the  diagnosis. 

Enlarged  spleen,  if  '-t  disturbs  the  position  of  the  heart,  raises 
it  instead  of  pushing  the  heart  to  the  right.  It  does  not  interfere  with 
the  respiratory  sounds  of  the  left  side,  nor  cause  bulging  of  the  in- 
terco.stal  spaces.  Posteriorly  the  perciission  sounds  are  normal  at  the 
pulmonary  base,  where  they  should  be  first  affected  in  pleurisy.  (Se(v 
also  Pneumonia  for  further  differences.) 

The  urine  in  pleurisy  presents  a  marked  contrast  to  that  of  pneu- 
monia. While  the  organic  solids  are  increased  and  the  volume  dimin- 
ished, yet  the  chlorides,  sulphates  and  phosphates  are  but  little 
changed  and  albumin  is  very  rare.  Peptone  is  often  present  during 
resolution  and  indicates  absorption  of  the  exudate. 

PNEUMOTHORAX. 

Definition.  The  presence  of  air  in  the  pleural  sac.  Since  air  is 
almost  never  present  unassoeiated  with  an  effusion,  either  serous  or 
purulent,  we  therefore  have  hydro-pneumothorax  or  pyo-pneumo- 
thorax,  as  the  case  may  be. 

Air  may  find  entrance  into  the  sac  from  perforation  of  the  pa- 
rietal layer  of  the  pleura  or  from  perforation  of  the  visceral  layer. 
The  latter  is  much  the  moi-e  common  and  the  largest  majority  of  all 
cases  results  from  tuberculous  iilceration.  Emphysema  probably  stands 
second  as  a  cause.  The  left  side  is  more  often  affected  than  the  right. 
The  organs  are  then  displaced  to  the  right  and  the  lung  may  be  col- 
lapsed and  pressed  against  the  spine  as  in  pleurisy. 

The  amount  of  associated  effusion  varies.  Some  cases  are  not 
discovered  until  post-mortem  examination  is  made. 


126  PLEURISY 

The  I'liijsual  Signs  vary  eousiderably  according  as  to  whethor 
air  alone  is  present  or  whether  it  is  associated  with  eftusion. 

limpcction  reveals  asymmetry  with  enlargement  and  ininiohility 
of  the  injured  side,  this  half  of  the  chest  being  in  the  position  as- 
sumed in  full  voluntary  expansion.  This  is  easily  demonstrated  by 
noting  the  resulting  symmetry  on  causing  the  patient  to  forcibly  in- 
spire, the  asymmetry  returning  on  forcible  expiration.  Uulging  of 
the  intercostals  may  be  present  and  it  is  to  bv  noted  that  there  is  no 
recession  of  the  spaces  on  inspiration.  This  is  especially  the  case 
if  the  opening  into  the  pleura  is  valve-like  so  that  there  is  actually  in- 
creased inter-thoraeic  air  pressure,  as  is  often  the  case.  The  heart  im- 
pulse is  generally  displaced  to  the  right.  The  costal  movements  of 
the  opposite  side  are  increased.  Vocal  fremitus  is  diminished  or 
absent. 

Mensuration.  The  tape  shows  marked  iuereasr  in  the  measure- 
ments of  the  affected  side,  and  little  or  no  change  with  expiration. 

Percussion  elicits  a  tympanitic  resonance  over  the  whole  of  the 
expanded  side.  The  note  varies  with  the  amount  of  air  imprisoned 
within  the  cavity  and  the  degree  of  tension  under  which  it  exists.  It 
may  be  vesiculo-tympanitic  if  little  or  no  pressure  is  exerted  or  it 
may  be  purely  tympanitic,  indicating  tension  and  pulmonary  com- 
pression. Often  it  is  amphoric  with  a  i-ich  metallic  quality.  The 
pitch  varies  with  the  conditions  named  and  deserves  especial  mention. 
If  the  ingress  and  egress  of  air  are  free  the  pitch  is  low,  and  may  be 
raised  by  causing  the  patient  to  inspire  deeply  and  hold  the  mouth 
closed.  Prom  this  pitch  the  note  rises  with  the  pressure  until  flatness 
is  reached.  "When  the  air  is  confined  under  such  extreme  pressure 
that  vibration  from  percussion  is  impossible,  the  resulting  note  must 
be  flat  and  toneless.  A  lesser  tension  elicits  a  very  high-pitched  per- 
cussion note.  Percussion  of  the  lower  areas  of  the  chest  yields  dull- 
ness owing  to  the  presence  of  fluid,  but  it  is  to  be  noticed  that  the 
tympanitic  areas  often  extend  much  beyond  their  normal  fields.  "When 
fluids  are  present  the  flatness  elicited  by  percussion  changes  with 
changes  in  the  position  of  the  patient.  This  variation  of  the  percus- 
sion level  occurs  much  more  readily  and  frequently  than  in  pleurisy, 
where  it  is  often  impossible  to  demonstrate  any  such  change. 

Auscultation.  Absence  of  all  vesicular  murmur  is  noticed.  Such 
breath  sounds  as  may  be  occasionally  heard  are  feeble,  indistinct  and 
distant  and  are  never  vesicular,  but  rather  amphoric  in  character,  or. 


127 


as  occurs  in  pleurisy  when  the  pressure  is  such  that  the  vesicles  are 
obliterated,  we  get  bronchial  breathing.  The  vesicular  mui-mur  on 
the  sound  side  is  intensified  and  approaches  puerile  breathing.  The 
vocal  resonance  is  amphoric  and  may  be  imitated  by  speaking  softly 
into  a  large  bottle.     Rales  are  generally  present  and  assume  peculiar 


Fig.  36 — Physical  signs  in  pneumothorax  (Patton).  A  Tympanitic  percussion 
note,  breathing  suppressed,  tubular  or  amphoric,  voice  sounds  metalhc  or 
amphoric;  metallic  tinkling.  B  Dullness,  absence  of  all  sounds.  C  Harsh 
breathing  (upper  portion),  increased  percussion  note  2nd  increase  in  pitch 
of  voice  and  respiratory  sounds  (lower  portion).  D  Displaced  area  of 
cardiac  dullness.     E  Displaced  spleen. 

characters.  One  very  characteristic  sound  is  known  as  metallic  tink- 
ling and  may  be  likened  to  drops  of  water  falling  against  a  very  thin 
wine  goblet,  or  to  striking  the  goblet  with  a  delicate  wire.  These 
phenomena  were  first  described  by  Laennec.  but  his  explanation  of 
the  manner  of  their  production  is  of  doubtful  correctness. 


128  pi.Ei-uit^v 

Trousseau  describes  a  valuable  sign.  I'laee  a  coin  over  the  alt'ect- 
ed  side  aud  strike  it  sharply  with  the  edge  of  another  coin  while  the 
ear  is  held  against  the  chest  of  the  i)atient.  A  bell-like  ringing  or 
tinkling  is  heard  which  is  pathognomoiiie,  and  may  be  obtained  even 
when  intrapleural  tension  is  so  high  as  to  yield  percussion  dullness. 

Succussion  splash  may  be  elicited  by  violent  oscillation  of  the  pa- 
tient while  the  ear  is  applied  to  the  chest  wall.  The  patient  should 
be  in  a  sitting  posture.  Sometimes  the  patient  himself  is  aware  of 
this  phenomenon.  It  even  may  be  felt  by  superimposing  the  hands 
over  the  ribs,  one  on  either  side,  while  the  patient  (piickly  moves  the 
body.  This  sign,  which  is  known  as  Ilippocratie  succussion,  is  fully 
described  under  Auscultation  in  the  introduction.  It  requires  for  its 
production  the  presence  of  both  air  and  fluid  in  a  cavity.  When  pi-es- 
ent  its  diagnostic  significance  is  absolute.  Xn  one  should  he  uiislcd 
by  the  possible  splash  of  a  stomach  partially  tilled  with  li(|uid  con- 
tents. 

In  pneumothorax  the  organs  are  often  displaced,  especially  the 
heart  and  liver.  The  first  may  be  pushed  either  to  the  right  or  to  the 
left :  the  latter  displaced  downward. 


SECTION  VII. 

PNEUMONIA. 

LOBAR  PNEUMONIA. 

Definition.  An  infiammatioD  of  the  Inug  substance  accompanied 
by  exudation  from  the  blood  vessels  and  the  growth  of  pathogenic 
bacteria,  being  due  to  a  specific  infection. 

The  lower  lobe  of  the  right  lung  is  most  often  the  seat  of  the  dis- 
ease, and,  next,  it  most  frequently  attacks  the  lower  left  lobe.  The 
lower  lobes  are  affected  nearly  three  times  as  often  as  the  iipper  lobes. 

The  physical  signs  vary  with  the  stages  of  the  disease,  which  are 
called,  respectively,  stage  of  congestion,  stage  of  red  hepatization, 
and  stage  of  gray  hepatization. 

FIRST  STAGE. 

No  consolidation  has  yet  taken  place  although  there  is  some  exu- 
•dation  into  the  air  vesicles. 

Physical  Signs.  Inspection.  The  patient  may  lie  on  the  affected 
side,  or  be  propped  up,  leaning  toward,  or  "favoring,"  that  side. 
DyspncEa  at  this  stage  is  not  marked,  orthopnoea  is  not  frequent.  Ths 
movements  of  the  aft'ected  side  are  more  or  less  restrained. 

Palpation.    On  touch  the  fremitus  is  normal. 

Percussion.  The  percussion  note  is  at  first  unchanged  but  as  the 
air  spaces  are  trespassed  upon  the  note  becomes  higher  in  pitch,  its 
■duration  shorter  and  its  approaches  to  dullness  in  direct  proportion 
to  the  amount  of  exudate  into  the  air  spaces. 

Auscultation.  Very  early  in  the  disease,  even  before  exudation 
lias  taken  place,  the  respiratory  murmur  diminishes  in  intensity  over 
the  affected  area  and  becomes  correspondingly  exaggerated  in  other 
parts.  This  quiet,  suppressed  breathing  in  one  part  of  the  lung  with 
exaggeration  in  other  parts,  especially  on  the  opposite  side,  is  quite 
marked  even  in  the  preliminary  stages  and  should  always  suggest 
pneumonia.  Likewise  during  this  stage  of  enfeebled  respiration,  after 
«xudation  occurs,  on  drawina-  a  long  breath  the  sounds  over  the  in- 


LSO  PNEL-.MO.NIA 

disposeil  ai'ea  will  be  observi'd  to  havo  that  harsliiicss  of  i(ualily  and 
elevation  of  pitch  to  whieli  the  name  bruiiLlio-vaiictilar  breathiuj,'  is 
applied.  As  soon  as  exudation  takes  place  the  crepitant  rale  is  heard, 
the  distinctive  sound  of  the  first  stage  of  pneumonia.  This  rale  is 
a  tine,  crackling  sound  heard  close  to  the  ear,  occurring  at  the  end  of 
inspiration  and  may  not  be  audible  until  a  full  breath  is  drawn. 
Opinion  diflfers  as  to  whether  this  crepitus  is  due  to  a  fine  exudate 
upon  the  pleura  or  is  caused  by  ijifiltration  into  the  air  cells  and  finer 
bronchioles,  due  to  the  separation  of  the  sticky  exudation  with  in- 
flation of  the  cells.  While  a  priori  the  latter  view  seems  more  rea- 
sonable, yet  it  is  probable  that  the  former  is  correct.  Coar.ser  rales 
may  be  present  in  the  large  bronchi  and  may  mask  the  more  delicate 
crepitant  sound.     Moist  rales  are  seldom  present  at  this  stage. 

An  examination  of  the  urine  will  show  (iiiiiiniilidn  of  the  chlo- 
rides and  perhaps  albumin  will  be  found. 

SECOND  STAGE. 

luspeclio)!.  The  restricted  movement  of  the  affected  side  is  now 
marked  and  the  compensatory  or  exaggerated  breathing  on  the  oppo- 
site side  may  attract  attention  even  before  the  patient  is  uncovered. 
The  respirations  are  increased  in  frequency  and  are  of  a  labored 
character,  as  indicated  by  calling  into  play  the  accessory  respiratory 
muscles.  The  nostrils  dilate  on  inspiration,  ahvays  a  sign  of  inspira- 
tory dyspncea.  The  area  of  the  cardiac  impact  may  be  much  larger 
than  normal,  as  i)ointed  out  by  Graves,  especially  in  pneumonias  of 
the  left  upper  lobe.  The  cardiac  impulse  maj'  be  transmitted  through 
the  solidified  lung  .so  as  to  cause  marked  movement  of  the  chest  wall. 

Mensuration.  The  aft'ected  side  is  increased  in  volume  though 
the  increase  is  slight  and  not  sutifieient  to  obliterate  the  intercoi5tal 
spaces.     (Contrast  with  pleurisy.) 

Palpation.  Vocal  fremitus  is  generally  increased  over  the  con- 
solidated area,  as  is  to  be  expected.  Yet  for  some  unexplained  reason 
it  is  .sometimes  diminished  or  absent.  This  diminution  may  be  due  to 
the  closure  of  the  larger  bronchi  by  the  exudation,  thus  preventing 
the  voice  sounds  from  reaching  the  periphery.  In  such  eases  a  vig- 
orous cough  may  clear  away  the  obstruction  and  i-estore  the  fremitus. 
Lack  of  expansion  may  be  more  apparent  to  touch  than  to  sight,  espe- 
cially by  a  comparison  of  the  two  sides.  Friction  fi'emitus  often  may 
be  felt.     (See  pleural  fremitus.) 


PNEUMOAMA  131. 

Percussion.  There  is  marked  percussion  dullness  over  the  area 
of  infiltration.  The  note  varies  with  the  degree  of  distention  of  the 
ail-  spaces.  Sometimes  the  note  is  almost  tympanitic,  or  at  least  sug- 
gests that  quality,  and  varies  therefrom  to  marked  dullness,  but  never 
reaches  that  absolute  flatness  which  has  been  described  as  the  distinc- 
tive quality  of  etfusion.  Where  consolidation  is  central  and  surround- 
ed by  distended,  pervious  tissue,  we  get  the  tympanitic  note,  and  here 
even  deep  percussion  may  not  elicit  dullness.  In  the  aged  especially 
must  we  be  on  our  guard  against  variations  and  irregularities.  Dur- 
ing this  stage  sometimes  percussion  elicits  the  cracked-pot  sound.  ( See 
Phthisis.) 

Auscultation.  The  crepitant  rale  appears  with  the  exudation 
upon  the  pleura.  It  may  persist  through  the  second  stage,  but  some- 
times is  absent  altogether. 

The  respiratory  sounds  are  propagated  from  the  large  bronchi 
through  the  consolidated  tissue  and  have  therefore  the  quality  of  the 
tubes  which  remain  iiervioiis.  The  breathing  is  therefore  tubular, 
much  intensified  and  is  similar  in  quality  to  that  heard  when  in  health 
the  stethoscope  is  placed  over  the  roots  of  the  lungs  or  over  the  large 
bronchi.  Breathing  may  be  more  intense  and  bronchial  in  this  dis- 
ease than  in  any  other  pulmonary  condition.  Rales  may  or  may  not 
accompany  this  blowing  respiration. 

From  the  above  explanation  it  follows  that  in  cases  where  the 
large  bronchi  are  closed  by  exudate,  the  bronchial  respiration  is  also 
absent.  Bronchophony  is  generally  heard  when  bronchial  breathing 
is  heard,  but  if  consolidation  is  imperfect  it  may  be  absent.  It  maj- 
have  the  bleating  or  nasal  quality  to  which  the  name  egophony  is 
applied. 

THIRD  STAC4E. 

Gray  Hepatization.  Movements  gradually  return  and  respira- 
tory harmony  is  established.  Respirations  become  less  labored  and 
less  frequent  as  permeability  returns.  If  there  has  been  enlargement 
of  the  affected  side,  it  disappears.  With  increased  motion  of  the  lung 
the  crepitant  rale  may  be  manifest. 

As  softening  progi'esses  air  enters  the  vesicles,  but  the  tubes  are 
loaded  with  the  softened  products  and  rales  are  heard  over  all  parts,, 
coarse  and  bubbling  as  well  as  finer,  dryer  sounds,  crepitant  and  sub- 
crepitant.     The  name   rales   redux  has  been   given   to  this   process. 


132  I-NKIMONIA 

BroiK-hial  l)rfatliiii,Lr  and  broiiehophoiiy  disappear  and  are  replaced 
by  the  gentle  vesicular  rustle.  Last  of  all  to  disappear  is  the  dull  per- 
cussion note  and  the  cracked-pot  sound.  Impaired  resonance  over 
certain  areas  may  permanently  remain. 

It  will  be  seen  that  the  third  statre  repeats  larjrely  the  inspection, 
palpation  and  auscultation  signs  of  the  first  stage  in  inverse  order. 
The  third  stage,  which  is  the  stage  of  resolution,  occupies  ten  or  twelve 
days.  The  la.st  sign  of  this  stage  is  the  crepitant  rale,  the  return  of 
which  is  known  as  "crepitans  redux.""  When  it  is  replaced  by  nor- 
mal vesicular  breathing,  dullness  should  have  disappeared. 

Besides  recovery  and  death,  two  other  terminations  should  he 
noticed,  abscess  and  gangrene.  Osier  asseils  that  ordinary  fibrinous 
pneumonia  never  terminates  in  tuberculosis,  that  such  suppo.sed  ca.ses 
were  tu])erculous  from  the  outset. 

Abscess  results  from  pneumonia  in  about  three  i>r  four  per  cent. 
of  the  cases.  Small  cavities  may  unite  into  one  involving  a  consid- 
erable portion  of  the  lobe.  The  sputum  becomes  abundant,  purulent, 
contains  elastic  tissue  and  may  contain  crystals  of  chole.sterin  or  of 
hsmatoidin. 

The  cough  comes  on  in  severe  paroxysms,  with  profuse  expec- 
toration. The  fever  is  at  first  remittent,  then  intermittent  and  hectic. 
The  signs  of  cavity  are  not  usually  present. 

Gangrene  occurs  about  as  often  as  abscess,  but  may  present  no 
signs  except  post-mortem.  It  may  occur  with  abscess.  If  the  sputum 
becomes  foetid  and  exhibits  the  characteristics  of  gangrene,  the  diag- 
nosis is  clear. 

Special  Symptoms.  Herpes  develops  in  about  one-third  of  all 
cases.  Coming  on  early  it  is  of  decided  diagnostic  value  as  it  appears 
in  scarcely  any  other  i-espiratoi-y  disease,  although  it  occurs  about  as 
frequently  in  malaria  and  cerebro-spinal  meningitis  as  it  does  in 
pneumonia.  The  commonest  seat  of  development  is  about  the  angle 
■of  the  mouth  and  nose.  Less  usual  .seats  are  about  the  eye,  ear,  the 
genitals  or  the  anus.  The  vesicles  appear  in  a  crop  of  half  a  score  to  a 
scoi"e,  disappearing  in  a  few  days,  leaving  behind  dry  scabs. 

Chill.  In  no  other  disease  except  malaria  is  chill  .so  apt  to  be  an 
initial  symptom.  Often  it  comes  on  at  night  and  is  always  severe, 
lasting  fifteen  to  forty-five  minufes.  It  is  followed  by  rapidly  rising 
fe^er  which  runs  a  course  between  100°  and  105°,  F.,  most  frequently 
fallintr  bv  crisis  between  the  third  and  the  eleventh  dav. 


PNEUMONIA  133 

Pain,  ilost  cases  are  ushered  in  by  sharp,  laucinatiug  pain, 
which  is  due'  to  the  accompanying  pleurisy  and  therefore  has  its  usual 
seat  over  the  affected  side,  yet  the  pain  often  appears  before  the 
pleuritic  friction  is  observable  and  may  be  referred  to  some  distant 
point.  Pain  is  generall}'  most  marked  in  the  mammary  or  the  axillary 
region.  In  old  persons  it  is  less  distinct  or  absent.  In  central  pneu- 
monias it  is  absent.    It  is  often  referred  to  the  abdomen  in  children. 

Pulse  varies  with  the  fever  but  rises  to  100°  or  120°. 

Dyspnoea  occurs  early  and  is  severe.  The  respirations  quicklj^ 
reach  thirtj' ;  later  fifty  or  sixt.y  in  the  adult  is  not  imcommon ;  eighty 
is  not  extraordinary,  especially  if  both  lungs  are  involved.  In  chil- 
dren one  hundred  is  not  unknown.  The  movements  are  restrained 
on  account  of  pain,  hence  are  shallow,  often  ending  in  an  expiratory 
grunt.  Deep  breathing  elicits  exquisite  pain.  The  respiration-pulse 
ratio  is  more  significant  in  pneumonia  than  in  any  other  disease, 
reaching  one  to  two  or  one  to  one-and-a-half  in  some  cases,  instead 
of  the  customary  ratio  of  one  to  four.  Thus,  a  pulse  rate  of  100  or 
110  may  coincide  with  a  respiration  rate  of  50. 

The  cough  is  very  painful  and  therefore  restrained.  It  is  at  first 
short,  frequent  biit  single,  dry  and  hard.  Later  it  is  accompanied 
by  characteristic  expectoration.  In  children  and  in  old  people  the 
cough  may  be  slight  and  attract  little  attention. 

EXPECTORATION. 

The  first  expectoration  consists  of  small,  glairy  mucus,  arising 
from  the  concurrent  bronchitis.  Within  twenty-four  hoiirs  after  the 
initial  chill  the  sputum  assumes  distinctive  characters,  becoming  ex- 
ceedingly tenacious,  viscid  and  gelatinous  or  gluey,  then  tinged  with 
blood.  The  cup  may  now  be  inverted  without  spilling  the  contents. 
The  mass  trembles  like  jelly.  The  patient  has  difficulty  in  expelling 
the  stielry  masses.  Prom  being  blood-tinged,  it  becomes  decidedly 
colored  and  the  designation  "prune-juice  sputum"  is  sometimes  ap- 
plicable, though,  in  my  experience,  infrequently  in  frank  pneumonias. 
In  eases  of  the  asthenic  type  it  is  common.  The  term  "rusty"  better 
describes  the  secretion  in  the  majority  of  instances.  The  amount 
varies  from  one  to  four  ounces  in  the  twenty-four  hours.  After  the 
crisis  the  color  changes  to  greenish,  then  yellowish  purulent  masses 
are  expectorated  and  gradually  it  fades  away.  Sometimes  after  crisi= 
it  ceases  suddenly. 


134  PNEUllOXlA 

Microseopii-ally  the  sputuni  is  t'oiiiid  to  coutaiu  do^i'iRTated 
hronehial  and  alveolar  epitheliiiiii,  inuciis,  leucocytes,  blood  corpiiseie.s 
changed  and  unchanged,  minute  fibrinous  casts  of  the  capillary 
bronchi  and  alveoli,  hivniatoidin  cry.stals,  the  micrococcus  lanceolatus 
and  sonu'tinies  other  organisms,  such  as  Priedliinders  bacillus  |ineu- 
iiioiiia-.  st:i|)b\liic(n'cus  ;uui  slreptoeoccus  pyogenes  and  xai'idus  nthi-rs. 

HAl'TEKIOLOGY. 

Owing  to  the  confusion  which  is  apt  to  exist  in  the  mind  dI'  Ihr 
student  with  regard  to  the  liacteriology  of  pneunionia  the  I'dllowing 
statements  are  made: 

Friedliinder  in  1882  described  capsulated  bacilli  as  being  of 
constant  occurrence  in  the  alveolar  exudate.  They  wn-e  named 
"  Friedliinder  "s  bacillus  pneumoniic. '"  He  believed  they  were  path- 
ogenic. Frankel  and  others  subseciuently  showed  that  this  bacillus 
was  of  comparatively  rare  occurrence  in  pneiniKinia.  and  thai  an- 
other, discovered  by  Sternberg,  was  present  in  the  sputa  of  nearly  all 
eases.     Priedlander's  bacillis  is  now  named,  "'riu'  pneumo-baeillus. " 

This  second  organism  has  been  known  by  various  and  confusing 
names  and  is  .still  called  the  diploeoccus  pnenmonia'  and  also  the 
pneumoeoecus  of  Frankel. 

In  1888,  Klein  desci'ibed  yet  another  bacillus,  known  as  Klein's 
bacillus  pneumoniae. 

In  some  cases  of  the  disease  only  streptococci  are  found.  Fran- 
kel's  pneumoeoecus  has  been  found  in  the  saliva  and  bronchial  .secre- 
tions of  healthy  individuals.  In  some  cases  of  pneumonia  none  of 
the  above  organi-sms  is  present. 

The  diploeoccus  pneumonia\  also  called  the  micrococcus  lanceo- 
latus, and  pneumoeoecus,  is  oftenest  foinid  in  the  .sputum,  but  in  the 
absence  of  physical  signs  and  clinical  .symptoms  does  not  indicate 
the  presence  of  the  disea.se,  since  it  may  be  found  in  healthy  per.sons. 

Method.  Smear  two  cover  glasses  with  the  sputum,  rub  together 
into  a  thin  layer,  separate,  dry  in  the  air  and  fix  by  passing  a  few 
times  through  the  flame  of  an  alcohol  lamp.  Immerse  in  a  one  per 
cent,  solution  of  acetic  acid  for  two  minutes,  draw  off  the  excess  of 
acid  with  a  pipette  and  .stain,  first  in  a  saturated  .solution  of  anilin 
water,  then  in  gentian  violet.  Wash  in  water  and  examine.  The 
organism  is  a  rod-.shaped  diploeoccus  surrounded  by  a  capsule 
(Simon). 


PNEUMONIA  135 

BLOOD  CHANGES. 

The  most  common  and  characteristic  blood  phenomenon  is  leu- 
■cocytosis.  The  normal  number  of  leucocytes  per  cubic  millimeter  does 
not  exceed  ten  thoiisand.  In  pneumonia  it  may  increase  to  30,000 
or  40,000.  Osier  has  seen  63,000.  Leucocytosis  increases  with  tem- 
perature and  disappears  with  crisis.  Its  absence  portends  grave  con- 
sequences. Its  persistence  means  delayed  resolution.  Since  leucocy- 
tosis does  not  occur  in  influenza,  its  presence  is  of  diagnostic  value. 

THE  URINE  IN  PNEUMONIxi. 

The  quantity  is  diminished  to  one-third  or  one-half.  Uric  acid 
and  urea  are  increased  and  large  deposits  of  pigmented  urates  occur 
at  critical  stages.  They  are  stained  brown  or  red.  The  specific  grav- 
ity is  1025  to  1035.  Excess  of  mucus  causes  the  fluid  to  become 
quickly  alkaline.  The  chlorides  are  greatly  diminished  or  even  absent 
during  the  first  and  second  stage,  or  even  iintil  convalescence  sets  iu. 
Their  return  is  a  favorable  indication.  The  sulphates  increase. 
Nearly  fifty  per  cent,  of  all  the  cases  show  albumin  diiring  consolida- 
tion and  its  presence  is  distinctly  unfavorable.  Diminution  of  the 
total  solids  is  also  unfavorable.  Sometimes  nephritis  is  intercurrent  or 
is  a  sequel  of  pneumonia. 

DIFFERENTIAL  DIAGNOSIS. 

Pneumonia  in  the  first  stage  resembles  pulmonary  oedema.  The 
latter  differs  by  the  presence  of  liquid  crackling  rales  occurring  at 
the  most  depending  portions  of  the  lungs  and  on  both  sides,  while 
pneumonia  is  usually  confined  to  one  lung.  Further,  the  frothy 
sputum,  the  genei'al  distribution  of  the  rales,  their  coarser  character, 
the  cyanotic  lips,  the  noisy  breathing,  the  absence  of  fever,  in  oedema, 
prevent  error.  When  not  the  immediate  precursor  of  death,  cedema  is 
not  an  acute  condition. 

In  the  consolidation  stage  it  may  be  confounded  with  pleural 
effusion.  ,It  differs  from  the  latter  in  that  bulging  is  absent,  vocal 
fremitus  instead  of  being  absent  is  increased,  by  the  fact  that  the 
percussion  note  is  never  wooden  or  absolutely  flat  and  that  its  area 
does  not  move  with  changes  in  the  position  of  the  patient,  that  the 
respiration  sounds  are  intensified  and  tubular  instead  of  absent  in 
pneumonia,  and  that  when  occasionally  present  in  effusion  they  are 
indistinct,   distant   or  deep-seated.      Pleurisy   is   often    without   rales 


i:j6  I'XEr.MoNiA 

iiiid  tlu'  s|)uluiii  is  I'rolhy.     I'lU'iiiiKnna  does  not  displace  any  of  the 
organs. 

From  phthisis  it  ditiVrs  both  in  the  history  and  in  the  course  and 
progress  of  the  disease.  Tuberculosis  advances  from  the  apex  down- 
ward. Pneumonia  is  confined  oftenest  to  one  lobe  and  that  the  lower 
lobe,  is  much  more  acute,  the  hectic  flush  is  absent  as  are  the  night 
sweats.  The  character  of  the  cough  and  sputum  is  different,  there 
are  no  tubercle  bacilli  present.  The  pulse-respiration  ratio  is  inverted, 
that  is  to  say,  in  pneumonia  the  pulse  is  slower  than  called  for  by  the 
respiration  rate,  while  in  phthisis  it  is  faster.  The  dyspnoea  of  pneu- 
monia is  much  more  striking  than  that  of  phthisis.  It  is  only  in  those 
eases  of  acute  phthisis  that  appear  after,  pneumonia,  that  the  physi- 
ciau  must  be  on  his  guard. 

BEONCHO-l'XEU.MONIA. 

Synonyms:  Capillary  Bronchitis.  Lobular  Pneumonia,  sometimes 
Catarrhal  Pneumonia. 

Definition.  An  intlanimation  of  the  terminal  bronchus  and  the 
vesicles  which  constitute  a  pulmonary  lobule,  due  to  the  invasion  of 
the  lung  by  various  kinds  of  microbes.  It  is  lobular,  in  contradistinc- 
tion to  lobar,  pneumonia. 

Holt's  statistics  give  a  propoi-tion  of  two  eases  out  of  every  three 
as  .secondary  to  some  other  disea.se. 

Bacteriology.  The  organisms  most  commonly  found  in  broncho- 
pneumonia are  bacillus  influenza,  micrococcus  lanceolatus.  streptococ- 
cus pyogenes,  staphylococcus  pyogenes  aureus  et  albus,  Friedlander's 
bacillus  pneumonias  also,  the  organisms  of  the  associated  disease  when 
the  process  is  secondary,  as  the  bacillus  of  diphtheria.  The  infection  is 
almost  always  mixed. 

In  typical  form  broncho-pneumonia  is  a  disease  of  childhood, 
usually  attacking  children  under  two  years.  It  is  either  a  primary 
disease  or  is  secondary  to  bronchitis,  measles,  whooping  cough,  diph- 
theria, ileo-colitis,  scarlet  fever  or  influenza,  in  the  order  named 
(Holt).  It  also  follows  other  diseases  but  less  frequently.  Wilkes 
mentions  it  as  occurring  after  extensive  burns  of  the  skin.  It  occurs 
in  the  course  of  typhoid  fever.  It  follows  the  inhalation  of  foreign 
sub.stances,  giving  a  distinct  type,  the  so-called  inhalation  or  degluti- 
tion type,  due  to  benumbing  of  the  larynx,  as  after  apoplexy,  in 
lu-a'iiiia.  and  post-operative  pneumonia. 


PNEUMONIA  137 

Rickets  and  malnutrition  are  predisposing  causes  and  furnish  a 
fruitful  mortality.  In  the  aged  it  often  terminates  a  chronic  bron- 
chitis. 

The  disease  is  bi-lateral  but  one  side  usually  bears  the  brunt  of 
the  attack.  The  lesions  are  small  areas  of  consolidation,  often  sur- 
rounded by  areas  of  over-distended  cells  alternating  with  small  areas 
of  collapsed  lobules,  which  are  depressed  below  the  surface.  The  con- 
solidated spheres  change  from  brown  to  gray,  and  then  to  yellow 
with  age.  They  may  be  separate  and  remain  fairly  scattered,  but 
some  aggregate  and  by  their  confluence  form  large  racemose  bunches 
of  consolidation,  -n-ith  interspersed  air  cells,  so  that  an  entire  lobe  is 
never  solidified.  The  lower  lobes  are  affected  oftenest  and  collapsed 
lobules  are  found  near  the  base  of  the  lungs.  The  small  bronchi,  the 
alveoli,  and  occasionaly  even  the  large  bronchi  are  filled  with  inflam- 
matory products  and  proliferated  cells.  "When  pressed  they  exude 
purulent  mucus. 

The  eases  terminate  by  softening,  abscess,  gangrene  (bronchiec- 
tasis often  so  terminates),  return  to  normal  or  become  chronic 
(chronic  pneumonia).  So  much  of  the  morbid  anatomy  is  absolutely 
necessary  for  a  proper  understanding  of  the  various  signs  and  sjnnp- 
toms  encountered. 

Associated  Lesions.  The  bronchial  glands  enlarge  but  do  not 
undergo  softening.  The  right  heart  dilates,  due  to  the  obstruction 
encountered  in  the  kings,  and  this,  leads  to  venous  engorgement  of  tha 
organs  connected  with  the  systemic  circulation,  as  the  spleen,  liver, 
and  kidneys.     Intestinal  catarrh  is  for  this  reason  often  associated. 

Course  and  Symptoms.  The  primary  attack  often  sets  in  with  a 
con\T.ilsion,  sometimes  with  a  chill,  the  temperature  rises  rapidly  to 
103°  and  varies  between  103°  and  105°,  but  is  fairly  constant.  Cere- 
bral symptoms  may  mask  the  pulmonary  lesion,  or  what  is  more  likely ,^ 
the  disease  may  be  mistaken  for  lobar  pneumonia. 

The  secondary  form  begins  as  does  the  primary  with  accession  of 
fever,  cough  and  dyspncea,  rarely  with  chill.  The  fever  is  more  irreg- 
ular and  ranges  between  102°  and  104°.  Morning  temperature  may 
be  higher  than  evening.  The  cerebral  symptoms  if  they  occur,  come- 
on  early  and  go  quickly.  Breathing  is  from  fiftj'  or  sixty  to  eight>' 
per  minute.     (Compare  lobar  pneumonia.) 

Physical  Signs.  Inspection.  Patient  rests  propped  up  in  bed 
with  the  head  high,  respirations  are  short  and  shallow,  alse  nasi  are 


I'iS  PNEUMONIA 

widely  dilated.  The  face,  at  first  ])ak'.  soon  becomes  livid  and  theu 
cyanotic.  'I'lic  ixincssidii  is  anxious.  The  breathing  is  labored,  the 
inspii-ations  are  short,  the  expirations  are  prolonged,  there  is  little 
true  expansion.  The  .sternum  rises,  but  there  is  recession  of  the  lower 
interspaces,  the  submammary  and  epigastric  regions,  with  inspiration. 
The  tongue  is  dry,  the  skin  hot  and  dry  or  alternates  with  jiei'spira- 
tion.  The  pulse  is  small,  quick,  rapid  and  may  be  uncountable.  The 
dyspn«?a  is  painful,  but  the  ett'orts  to  breathe  subside  somewhat  under 
the  influence  of  the  non-oxygenated  blood.  In  cases  which  survive 
dyspnoea  gradually  fades.     Emaciation  is  rapid. 

Palpation.     Fremitus  increases  with  the  amount  of  consolidation. 

Percussion.  The  note  is  normal  as  long  as  the  areas  affected  are 
few  and  scattered.  As  coalescence  occurs  the  resonance  becomes  im- 
paired. This  usually  develops  after  forty-eight  hours.  The  asso- 
ciation of  coalescence  and  collapse  gives  flatness,  but  in  the  most 
common  form  of  the  disease  the  patches  are  scattered  and  iniich  of 
the  lobe  remains  crepitant.  Early  in  the  disease  the  note  may  be 
hyper-resonant  in  front  and  along  the  over-distended  edges. 

Auscultation.  Breath  sounds  are  harsh  in  the  upper  lobes,  feeble, 
absent  or  bronchial  at  the  base,  depending  on  the  relative  amount  of 
the  three  factors  w'hich  inflitence  them,  viz:  consolidation,  collapse 
and  hyper-distention.  As  the  bronchioles  fill  with  exudate,  blowing 
breathing  predominates  and  expiration  may  be  jerky  and  grunting. 
The  rales,  at  fir.st  fine  and  subcrepitant,  soon  become  higher  aiul  whist- 
ling and  the  fine  crackling  rales  are  not  limited  to  inspiration. 

If  bronchiolitis  occurs  rales  become  metallic  and  high-pitched, 
associated  with  bronchial  breathing  and  bronchophony.  Rhonchi, 
sibilant  rales  and  other  signs  of  bronchitis  vary  with  the  extent  to 
which  the  tubes  are  involved.  Vocal  resonance  increases  with  con- 
solidation. 

Collapse  is  indicated  by  retraction  of  the  sid(\  absent  hi-eathing 
sounds,  absent  vocal  resonance  and  fremitus.  The  percussion  note  of 
collapse  is  not  as  dull  as  that  of  consolidation. 

The  cough  is  hard,  distressing  and  even  painful.  Occurring 
secondarily  to  bi-onchitis,  the  free  secretion  ceases.  A  cough  which 
was  loose  and  painless  now  becomes  short,  frequent,  dry  and  painful. 
The  secretion  becomes  viscid  and  is  coughed  up  with  difficulty.  It 
may  be  blood-tinged  but  is  never  rust-colored  as  in  pneumonia.  In 
children  expectoration  is  absent. 


PNEUMONIA  139 

Diagnosis.  The  secondary  forms  are  easiest  diagnosed.  If,  dur- 
ing convalescence  from  one  of  the  diseases  mentioned,  a  child  has  an 
accession  of  fever  with  cough,  a  rapid  pulse,  decided  increase  in  the 
respiration  rate  and  if,  on  auscultation  fine  crackling  rales  scattered 
about  the  base  of  the  lungs  are  heard,  one  may  safely  expect  broncho- 
pneumonia to  intervene. 

The  disease  closely  resembles  pneumonia  if  the  lobules  coalesce 
into  large  masses.  Broncho-pneumonia  occurs  oftenest  before  the 
second  year,  while  lobar  pneumonia  is  rare  before  the  third  year. 
Pneumonia  is  unilateral:  broncho-pneumonia  is  bilatei-al.  The  first 
is  primary,  the  second  is  oftenest  secondary.  Pneumonia  shows  fewer 
remissions  in  temperature  and  the  crisis  occurs  about  the  eighth  day. 

From  tuberculosis  the  diagnosis  is  often  made  by  postponement. 
It  is  an  aid  to  Imow  that  acute  miliary  tuberculosis,  without  softening, 
is  more  common  in  children  of  this  age  than  the  caseous  form,  but 
both  occur.  In  tuberculosis  the  upper  lobes  suffer  oftenest,  in  the 
pneumonias,  the  lower  ones,  and  typical  signs  may  be  detected  in 
the  vomited  matter,  shreds  and  tubercle  bacilli  may  be  found.  From 
meningitis  it  is  differentiated  by  recalling  that  brain  symptoms  ac- 
company the  onset  of  many  diseases  of  childhood,  and  the  dyspnoea 
and  the  cough  soon  draw  attention  to  the  lungs. 

EMBOLISM  OF  THE  PULMONARY  ARTERY. 

Sometimes   called   Embolic  Pneumonia,   Htemorrhagie    Infarct   or 
Pulmonary  Apoplexy. 

Definition.  A  conical  extravasation  of  blood  into  the  lung  sub- 
stance resulting  from  the  lodgment  of  an  embolus  in  a  branch  of  the 
pulmonary  artery.  The  embolus  must  arise  from  a  thrombus  which 
lias  formed  somewhere  in  the  venous  system,  and  which,  becoming 
detached  and  passing  through  the  cavities  of  the  right  heart,  ulti- 
mately blockades  a  branch  of  the  pulmonary  artery.  During  preg- 
nancy such  a  thrombus  may  form  in  the  venous  system  of  the  pelvis 
or  in  the  femoral  vein  (phlegmasia  alba  dolens).  During  typhoid 
fever  it  may  arise  from  thrombus  of  the  saphenous  or  femoral  vein. 
So  also  in  the  course  of  septic  diseases,  of  pleurisy  or  phthisis,  thrombi 
are  apt  to  form  in  the  veins  mentioned  or  in  the  jugular  vein.  In 
middle  ear  disease  they  may  form  in  the  lateral  sinus.  Further, 
•emboli  may  result  from  clots  formed  within  the  heart  itself,  in  dis- 


140  PNEUMONIA 

eases  of  that  ori:aii.  Fat  emboli  are  sometimes  fouml  after  death 
from  diabetes. 

Si/mploms.  A  small  embolus  may  eanse  only  a  transitory  o'dema 
or  hypersemia  which  soon  passes  away. 

Septic  emboli  cause  intiannnation,  and  trray  hepatization  follows 
the  wedge-shaped  infarct.  This  may  be  succeeded  by  abscess  or  gan- 
grene. The  typical  lesion  following  pulmonary  embolus  is  infarct, 
which  is  a  form  of  pulmonary  ha^noi-rhage.  The  area  is  cone-shaped, 
the  base  reaching  the  surface,  the  apex  corresponding  to  the  point  of 
obstruction.  If  small,  they  give  rise  to  few  symptoms.  If,  however, 
a  large  area  is  involved,  the  attack  comes  on  in  a  moment,  the  patient 
is  seized  with  agonizing  pain  and  the  most  intense  dsypnnea,  the  lieart 
is  irregular  and  tumultuous,  or  weak  and  impei-ceptiblt'.  aiul  death 
may  result  within  a  few  minutes. 

In  severe  but  not  fatal  eases  the  symptoms  are  somewhat  as 
follows : 

Inspection.  Patient  is  anxious,  breathing  is  rapid  and  panting, 
but  is  unobstritcted.  Sometimes  the  Cheyne-Stokes  type  supervenes, 
lips  are  blue,  skin  r-old  and  moist.  Heart  becomes  gradually  quiet 
and  feeble. 

Palpation  shows  increased  fremitus. 

Percussion  reveals  impaired  resonance  ovei-  the  limits  of  the 
infarct. 

AusculiatioH  shows  harsli  inspiration,  somewhat  lengthened  ex- 
piration, crepitant  and  suberepitant  rales,  and  even  bronchial 
breathing. 

Blood  appears  in  the  expectoration  after  twenty-four  to  thirty- 
six  hours.  In  some  cases  involving  large  areas  the  signs  are  those  of 
croupous  pneumonia,  but  the  outline  of  the  lobe  is  not  followed:  the 
disease  is  unaccompanied  by  pyrexia,  and  comes  on  much  more  rapidly 
than  is  possible  with  pneumonia. 

Occurring  in  the  course  of  mitral  disease  the  s.ymptoms  are:  pain 
in  the  side,  dyspnoea  and  possibly  haemoptysis,  with  the  expectoration 
of  dark,  blood-stained  sputum.  A  local  pleural  friction  sound  may 
mark  the  site  of  the  infarct.  Deep  percussion  may  reveal  tendei-- 
ness  (Head). 

Diagnosis.  The  suddenness  of  the  on.set,  the  eharaetei-  of  the 
dyspnoea — the   jiatient   breathing  deeply,  yet  conscious  of  a    laelc  of 


PNEUMONU.  141 

air — the  agouy,  the  absence  of  signs  of  obstruction,  should  suggest 
the  nature  of  the  disease. 

Asthma  is  accompanied  by  sonorous  and  sibilant  rhonchi. 

Lar\Tigeal  obstruction  shows  signs  of  impeded  air  entrance. 

OEdenia  shows  fine  crackling  rales  over  the  bases  of  both  lungs 
and  is  painless. 

Infarct  is  unilateral. 

The  knowledge  of  a  coexisting  phlebitis,  or  of  heart  disease,  aids 
materially  the  diagnosis.  If  seen  after  the  onset  and  without  a  knowl- 
edge of  the  history  of  the  ease,  the  disease  maj'  be  mistaken  for  pneu- 
monia. Xon-septie  cases  are  afebrile.  Septic  cases  are  followed  by 
chill,  rigor,  hectic,  and  the  familiar  chain  of  septic  sjTiiptoms. 

PULMONAEY  CEDEMA. 

Definition.  An  eifusion  of  serous  fluid  into  the  air  vesicles  and 
interstitial  tissues  of  the  lung  substance.  It  oeeurs  in  the  lungs,  as 
elsewhere,  by  reason  of  disturbances  of  the  circulation  and  changes 
in  the  vessel  walls,  hence  is  associated  to  a  more  or  less  extent  with  all 
diseases  producing  pulmonary  congestion.  It  gives  rise  to  few  symp- 
toms except  an  aggravation  of  the  existing  symptoms  of  the  asso- 
ciated disease. 

As  an  independent  entity  we  consider  the  pulmonary  oedema 
which  frequently  terminates  a  variety  of  acute  or  chronic  diseases, 
and  is  therefor  spoken  of  as  terminal  oedema.  Such  diseases  are  acute 
and  chronic  nephritis,  cardiac  diseases,  various  anaemias  and  diseases 
of  nutrition  and  cerebral  diseases.  It  is  prone  to  occur  in  maladies 
in  which  general  dropsy  exists.  Acute  oedema  may  follow  the  embolic 
obstruction  of  the  puhnonary  arteiy  just  described.  Sometimes  it 
follows  the  rapid  removal  of  large  quantities  of  fluid  from  the  pleural 
cavity  by  thoracentesis.  The  transudate  may  be  watery  serum  or 
blood-stained.    Very  acute  oedemas  are  almost  entirely  serous. 

Except  in  the  case  of  the  rapidly  produced  oedema  just  men- 
tioned, the  s\-mptoms  come  on  slowly.  Thej'  are  an  increasing  sense 
of  suffocation,  increasing  difSculty  of  breathing,  some  cyanosis,  a  weak 
pulse  and  a  cough  which  is  short  and  dry.  The  oedema  here  begins 
at  the  base  of  the  lungs  and  mounts,  the  s^inptoms  increasing  there- 
with. If  suddenly  developed,  the  above  sjTnptoms  are  much  aggra- 
vated, the  dyspnoea  is  severe  and  there  is  expectoration  of  abundant 
frothy   sputa,    which    may   be    blood-stained    or   hjemorrhasyic.      The 


142  fNEUMONIA 

dyspiia'a  depends  on  the  uumber  of  air  eells  oeeupied.  'I'lic  malady  i» 
afebrile,  bilatei-al. 

Percussion  gives  areas  of  inipaiivd  resonance,  ainoinilinu  to  dull- 
ness over  the  bases  and  dependent  i)ortions  of  the  luntrs.  Jjarge  eft'u- 
sions  give  marked  dullness. 

Auscultation.  The  vesicular  murnnir  is  feeble  or  absent.  Rales 
are  fine  or  coarse,  moist  or  liquid,  according  to  the  e.\tent  of  the  in- 
volvement. In  extreme  eases  the  breathing  is  bi-onchial.  and  eoar.se, 
rattling  rales  are  audible  at  a  di.stance. 

Broncho-pneumonia  intervening  as  a  secondary  disease  is  the 
only  att'ection  likely  to  be  confounded  with  pulmonary  cedema,  but 
the  mode  of  onset,  the  age,  the  fever,  the  glairy,  tenacious  expectora- 
tion and  the  scattered  areas  of  dullness  in  the  lattei-  will  clear  up 
the  doubt. 


SECTION  VIII. 

PULMONARY   TUBERCULOSIS   OR   CON- 
SUMPTION. 

Definition.  An  acute  or  chronic  febrile  infective  disease  of  the 
lungs,  caused  by  the  bacillus  tuberculosis,  characterized  by  diffused 
tuberculous  infiltration,  the  formation  of  tubercles  which  undergo 
caseation  or  sclerosis  and  which  may  ulcerate  or  calcify. 

VARIETIES. 

A.  Acute  phthisis.  1.  Tuberculo-pneumonic  phthisis  (Osier). 
2.  Acute  tuberculous  broncho-pneumonia. 

B.  Chronic  ulcerative  phthisis. 

C.  Fibroid  phthisis. 

D.  Miliary  tuberculosis  of  the  lungs. 

The  first  form,  acute  pneumonic  tuberculosis  of  the  lungs,  known 
also  by  the  name  of  "galloping"  consumption,  phthisis  florida,  is 
characterized  both  by  its  diffuseness  and  its  rapidity.  It  occurs  in 
both  children  and  adults.  Many  cases  occurring  in  children  are  mis- 
taken for  simple  lobar-pneumonia.  Since  an  entire  lobe  or  even  an 
entire  lung  is  affected,  and  inasmuch  as  physical  signs  are  identical 
with  those  of  pneumonic  hepatization,  in  which  condition  the  lung  is 
found  to  be  post-mortem,  the  mistake  is  excusable.  The  upper,  then 
the  lower  lobe,  then  the  entire  lung,  is  the  order  of  frequency  of 
involvement. 

The  physical  signs  are  those  of  consolidation ;  increased  frequency 
of  respiration,  dyspncea,  percussion  dullness,  marked  increase  in 
fremitus,  feeble,  vesicular  murmur  followed  by  suppression  and  then 
bronchial  breathing.  This  tubular  breathing  becomes  very  intense 
and  is  marked  as  early  as  the  fourth  day.  The  characteristic  crisis 
does  not  occur  by  the  tenth  day  and  the  sputum  becomes  muco-puru- 
lent  and  changes  to  green  color  (Traube).  Tubercle  bacilli  are  now 
found  in  the  sputum,  which  settles  the  diagnosis. 


144  PULMUNAKY    TLBIOKCLI.OSIS    UK    CONSUMPTION 

In  the  second  t'orni,  wliieli  Osier  deuoniinates  acute  tubereulous 
broueho-pneuniouia,  which  i'oi-ni  he  states  constitutes  the  majority  of 
cases  of  phthisis  dorida,  especially  in  children,  the  lesion  is  a  blockiug- 
up  of  the  small  tubes  with  cheesy  matter,  while  the  air  cells  of  the 
lobule  are  filled  with  the  products  of  catarrhal  pneumonia.  These 
areas  are  separated  by  areas  of  crepitant  tissue,  but  by  their  fusion 
an  entire  lobe  may  be  rendered  nearly  solid.  Owing  to  the  inter- 
spersed islets  of  crepitant  tissue  the  physical  signs  are  indefinite.  The 
first  positive  signs  are  usuallj'  those  of  deposits  at  one  or  the  other 
apex. 

The  respirations  are  markedly  increased  in  number,  the  sub- 
clavicular expansion  is  diminished.  Areas  of  diminished  resonance 
are  found,  more  generally  at  the  apices.  Over  these  areas  the  vocal 
resonance  and  fremitus  are  increased,  percussion  sounds  impaired, 
pitch  raised,  and  the  approach  to  flatness  is  directly  in  proportion  to 
the  volume  and  density  of  the  involved  tracts.  Auscultation  shows 
the  absent  vesicular  sounds,  replaced  by  rude  or  harsh  tubulai'  breath- 
ing, associated  with  rales,  numerous  and  varied  in  character.  The 
cough,  hacking,  troublesome  and  almost  continuous,  at  first  dry,  soon 
is  accompanied  by  expectoration  which  very  early  shows  the  presence 
of  tubercle  bacilli  and  ela.stic  fibers.  The  tongue  is  dry  and  brown, 
the  fever  high.  A  few  of  these  cases  survive  the  acute  stage  only  to 
become  chronic.  This  form  is  especially  prone  to  follow  measles  and 
whooping  cough. 

Chronic  Phthisis.  Ulcerative  Tuberculosis  of  the  Lungs.  As 
first  pointed  out  by  Laennee,  and  more  recently  in  the  admirable 
analysis  of  J.  Kingston  Fowler,  1888,  the  primary  lesion  is  most  often 
situated  from  an  inch  to  an  inch-and-a-half  below  one  or  the  other 
apex,  nearer  the  external  and  posterior  than  to  the  anterior  surface, 
whence  it  spreads  downward.  As  has  been  pointed  out  in  the  section 
on  topography,  the  lung  projects  from  one  to  one-and-a-half  inches 
above  the  clavicle,  hence  this  point  of  infection  would  lie  anteriorly 
under  the  center  of  that  bone.  The  situation  of  the  focus  towards 
the  posterior  surface  accounts  for  the  occasional  presence  of  demon- 
strable dullness  in  the  supra-spinous  fossa,  when  it  cannot  bo  made 
out  anteriorly.  The  right  apex  is  the  seat  of  the  primary  lesion  more 
frequently  than  the  left.  Fowler  further  calls  attention  to  the  fact 
that  the  lower  lobe  is  usually  affected  when  the  physical  signs  of  dis- 
ease at  the  apex  are  sufficiently  definite  to  allow  of  the  diagnosis  of 


PULMONARY    TUBERCULOSIS    OR     CONSUMPTION  145 

phthisis  being  made.  The  point  of  involvement  is  again  from  an  inch 
to  an  inch-and-a-half  below  its  apex,  which  corresponds  on  the  chest 
wall  to  a  point  opposite  the  spine  of  the  fifth  dorsal  vertebra.  Have 
the  patient  reach  the  arm  of  the  affected  side  around  his  opposite 
shoulder  and  place  his  fingers  iipon  the  spine  of  that  scapula.  The 
point  in  question  is  marked  by  the  inner  edge  of  the  abducted  scapula 
and  the  spine  named.  Cavities  are  usually  first  formed  where  the 
lesions  are  oldest,  and  must  be  as  hirge  as  walnuts  before  they  may 
be  positively  diagnosed  by  the  signs.  Hence  patient  and  repeated 
examinations  of  the  points  indicated  should  be  made. 

The  next  most  common  seat  of  cavity  after  the  localities  described 
is  in  the  second  or  third  interspace,  anteriorly,  outside  the  mid- 
clavicular line. 

It  is  of  extreme  importance  in  examining  a  suspected  case  of 
phthisis  that  the  orderly  sequence  laid  down  in  the  preliminary  chap- 
ter be  followed  carefully,  and  it  may  be  said  to  the  credit  of  the  diag- 
nostician that  in  the  vast  majority  of  the  cases  a  correct  conclusion 
may  be  arrived  at  by  the  intelligent  interpretation  of  the  physical 
signs,  before  it  may  be  reached  by  a  bacteriological  examination,  and 
with  no  less  certainty.  Before  attempting  to  explain  the  physical 
signs  which  accompany  the  tuberculous  invasion  of  the  lungs  in  the 
chronic  variety  of  the  disease,  it  is  necessary  to  name  the  lesions  pro- 
duced.   These  are : 

a.  Scattered  and  disseminated  tubercles.  These  so  long  as  they 
are  few  and  separated  give  rise  to  no  positive  signs. 

b.  Caseous  tubercular  masses  due  to  the  imion  and  breaking 
down  of  neighboring  tubercular  particles.  The  localities  in  which 
these  masses  are  prone  to  occur  earliest  have  been  pointed  out  in  this 
section.  The  signs  to  which  they  give  rise  vary  with  their  situation 
and  extent,  and  are  considered  below.  ■ 

c.  Tuberculous  cavities  (situation  noted).  These  may  have  soft 
walls  undergoing  ulceration  and  extending  their  areas  by  breaking 
down,  or  the  walls  may  be  composed  of  the  so-called  pyogenic  mem- 
brane, in  which  case  extension  is  slower.  The  formation  of  the  cavity 
wall,  the  size,  the  situation  (superficial  or  deep),  the  nature  of  the 
opening  into  it,  whether  full  or  empty,  all  modify  materially  the  signs. 

d.  Cavities  formed  by  dilatation  of  the  bronchi,  called  bronchi- 
ectasis (q.  v.).  The  form  of  such  cavities  may  be  cylindrical  (small 
bronchi)  or  globular  (large  bronchi). 


146  I'l  i.MdNAin-   n  BKiicn.osis  or    const'mptiox 

0.  Tile  \ariiiiis  t'liriiis  o\'  |ilfm-isy,  scinu'  nl'  wliicli  iirr  imariahlo 
acciinipaiiists  of  phthisis  diirinfj;  soiuf  part  ut'  its  course.  Throe  com- 
iium  variations  are  worth  iiaiiiiii^.  1.  Adhesive,  over  the  infiltration 
area,  which  results  in  a  local  jrluein'r  togethei'  nf  I  he  two  layers. 
2.  Perforative,  into  the  jileural  sac,  resultinu'  in  ciiipyiiua  and  pneu- 
mothorax. 8.  The  entire  pleura  may  become  the  seat  of  tubercular 
infiltration,  be  studded  with  tubercles,  thickened  and  may  cement  the 
lobes  into  a  single  mass. 

f.  Pulmonary  concretions,  'i'hcse  may  not  bo  ilill'on-ntiatod  by 
the  jihysical  sijjns,  but  are  often  couijhed  up,  as  are  also  bronchial 
concretions  found  in  chi'onie  bronchitis  with  dilatations.  Those  of 
phthisis  differ  from  those  of  broncliitis  by  l)oint;  moic  iii'os^nlar.  mm- 
uniform  masses  instead  of  pebble-like. 

The  physical  signs  are  best  considered  under  three  stasios : 

The  incipicnl  stage;  the  stage  of  complete  consolidation ;  the  stage 
of  softening  and  formation  of  cavities. 

THE  INCIPIENT  STAGE. 

Pulmonary  tuberculosis  is  met  with  in  chests  of  all  shapes  and 
capacities  but  the  long,  narrow  chest  is  the  prevailing  type.  Here 
the  intercostal  spaces  are  wide,  the  co.stal  angle  narrowed  and  the 
vertical  direction  of  the  iil>s  increased.  The  scapuhe  project  like 
wings,  often  one  more  than  the  other.  In  another  type  the  antero- 
posterior diameter  of  the  chest  is  lessened,  the  stermim  is  sunken,  the 
subclavian  spaces  flat  and  the  clavicles  prominent. 

Inspection  may  be  negative.  A  few  scattered  tubercles  give  rise 
to  no  phenomena  appreciable  by  our  coarse  senses,  but  as. soon  as  they 
are  sufficient  in  number  to  interfere  with  the  elasticity  or  to  increase 
the  conductility  of  the  lung  tissue,  they  produce  objective  signs.  On 
the  otheT  hand,  if  any  wasting  has  occurred  the  clavicles  are  rendered 
more  prominent  and  there  may  be  slight  flattening  below  one  or  the 
other  collar  bone.  Expansion  may  be  slightly  diminished  in  the  same 
region.  Deficient  apical  expansion  is  an  early  and  impoi'tant  sign. 
It  may  best  be  estimated  by  taking  a  position  behind  tli(  patient,  who 
should  be  seated,  and  looking  downward  over  tlio  slKuddors.  The 
breathing  will  be  somewhat  accelerated  but  shallowi-i'  than  in  iiealtb, 
and  the  apex  beat  may  show  acceleration  with  marked  quiokening  of 
the  impact. 

The  waveliko  shadow  caused  bv  the  rhvtbniical  I'iso  and  fall  of  the 


PtXlIOX.VEY    TUBERCi'LOSIS    (3R     COXSUilPTIOX  147 

diaphragm,  known  as  Litteu's  sign,  which  is  moi'e  fully  described  in 
the  section  upon  adherent  pericarditis,  is  seen  to  be  altered  early  in 
pulmonary  tuberculosis.  The  change,  for  the  most  part,  consists  in  a 
limiting  or  shortening  of  the  normal  shadow  on  the  affected  side.  The 
sign  is  important  and  always  should  be  searched  for  in  suspected  eases. 

Palpation.  Deficient  expansion  may  best  be  gauged  by  standing 
behind  the  patient  and  alternately  placing  the  fingers  in  the  sub- 
clavicular spaces  and  the  lateral  regions  of  the  chest  and  noting  the 
relative  motility.  So  also,  by  placing  the  thumbs  in  the  supracla^^c- 
ular  spaces,  while  the  fingers  are  placed  in  the  upper  intercostal 
spaces,  one  may  estimate  the  relative  expansion  of  the  apices  with 
fair  acc\u-aey.  (See  Fig.  17.)  Vocal  fremitvis  is  increased  wherever 
the  condensation  is  of  sufiieient  degree  to  assist  sound  conduction 
In  the  early  stages  it  is  diflScult  to  estimate  slight  increase  in  conduc- 
tion, especially  when  it  is  recalled  that  deposits  are  more  apt  to  occur 
on  the  right  side,  and  that  normal  fremitus  is  somewhat  greater  on 
this  side.  If,  however,  fremitus  is  greater  0)i  the  left  side  than  on  the 
right,  the  fact  is  significant.  Pleuritic  thickening  causes  diminution 
instead  of  increase  of  the  touch  fremitus. 

.  Mensuration.  The  tape  may  show  deficient  expansion  on  one 
side,  or,  what  is  more  general,  the  tape  encircling  the  body  imme- 
diately under  the  arm-pits  does  not  show  the  amount  of  expansion 
which  is  to  be  expected.    This  obtains  early  in  the  disease. 

Percussion.  Changes  may  be  recognized  on  percussion  which  are 
not  made  manifest  by  palpation.  The  first  positive  sigu  of  infiltration 
is  dviUness  and  its  most  usual  seat  is  immediately  underlying  the  clav- 
icle. It  is  most  surely  discovered  by  direct  percussion  on  that  bone, 
without  intermediation  of  the  pleximeter,  although  it  may  require  a 
cultivated  ear  to  detect  the  change.  Its  note  is  higher  and  shorter 
than  normal,  and  is  the  note  of  impaired  resonance.  The  difference 
in  the  two  sides  may  be  marked,  or  both  may  be  affected.  The  impair- 
ment when  not  at  the  apex,  is  of  ten  est  .just  below  the  ela^acle.  The 
note  .shoidd  be  elicited  during  natural  breathing,  on  forced  expiratiou, 
on  forced  inspiration  and  with  the  mouth  held  open,  as  directed  by 
Flint.  A  comparison  made  between  corresponding  ai'eas  while  the 
breath  is  held  after  forced  inspiration,  most  surely  detects  defective 
resonance,  when  present. 

Auscultation.    "When  positive  pei'cussion  changes  can  be  elicited 


148  I'n.Mo.NAKv   TunEuc'ui.usis  dr   cunsumption 

iibnoniialilit's  on  aust-ultatioii  aiv  invariably  present,  and  in  some 
cases  even  preeede  impaired  resonance.  The  earliest  aiisenltatory  sign 
is,  -iieuerally  speakinp:,  feeble  bi'eathint;',  owing  to  a  lessening  of  the 
tidal  air  entering  the  vesicles  of  the  affected  area.  Make  careful  com- 
parison between  the  two  sides  dm  ing  (piiet  breathing.  Inspiration  on 
the  diseased  side  may  be  inaudible.  Next  in  order  of  sequence  is  a 
prolongation  of  the  expiratory  murmur.  About  the  same  time,  or  a 
little  later,  the  inspiratory  sound  grows  harsher.  The  type  of  breath- 
ing now  becomes  broneho-vesienlar.  Vocal  resonance  is  increased  in 
direct  propoi-tion  to  the  amount  of  consolidation,  yet  in  not  a  few 
cases  it  will  be  found  absent  by  reason  of  early  pleurisy  having  thick- 
ened the  intervening  membranes,  thereby  masking  its  effect,  as  noted 
under  touch  fremitus.  Bronchitis,  when  present,  is  manifested  by 
rales.  A  soft  bruit  heard  in  the  pulmonary  or  subclavian  artery  is 
often  present,  and  Da  Costa  states:  "A  murmur  is,  indeed,  at  times 
present  in  the  pulmonary  artery  long  before  any  other  physical  indi- 
cation of  tubercle  is  discernible."  Also  interesting  is  the  so-called 
cardio-respiratory  murmur  met  with  in  phthisis,  caused  by  the  pro- 
pulsion of  air  from  the  tubes  by  the  impulse  of  the  heart.  It  is  best 
heard  during  inspiration,  in  the  antero-lateral  regions  of  the  chest. 
In  time  the  murnuir  is  systolic,  and  is  described  as  a  whiffling  bruit. 
(See  heart  murmurs.)  To  sura  up  the  signs  already  elaborated,  which 
allow  of  the  diagnosis  of  beginning  tuberculosis  with  almost  as  great 
certainty  as  does  the  finding  of  tubercle  bacilli  in  the  sputum,  and 
.often  long  before  their  occurrence  therein,  we  append  the  following: 
Modification  of  vesicular  murium"  at  apex. 
.  Adventitious  sounds,   artei'ial   or   respiratory. 

limited  to  the  apex. 

Percussion     dullness     in     claviculiir     area     or 

supra-spinous  fossa. 

Signs  of  y  Inerea.sed  fremitus. 

Impaired  ex]iansion  ov  riatleninu'  of  anterior 
incipient  ^^^^^,,^^.^  ^^^^.^^^,^^ 

phthisis.  1  '^ 

Shortness  of  breath. 

Sustained  rise  of  tempcraliiri'   with   iirobable 

morning  maxima. 

.Modification  of  Litten's  diaphragm  sign. 

Failing  health. 


PX.X3I0XARY    TL-BEECfLOSIS    OR    COXSUMPTIOX 


149 


STAGE  OF  CONSOLIDATION'. 

The  second  stage  gives  rise  to  signs  more  positive  and  more  pi'O- 
nouneed  than  the  first. 

Inspection  plainly  shows  loss  of  flesh,  prominence  of  cla-^-icles, 
ribs  and  interspaces.     A  hectic  flush  may  be  noted.     Flattening  is 


Fig-  37 — Extension  of  tuberculous  lesion  (Patton).  Dark  shade — ^primary  le- 
sion: light  shade — extension  of  primarx-  lesion;  X — secondary-  lesion  of  op- 
posite  apex. 

most  apparent  anteriorly  and  the  breathing  exctirsion  is  lessened  both 
with  quiet  breathing  and  diu-iag  forced  inspiration,  when  lack  of 
expansion  is  striking.    Expansile  efforts  may  be  painful. 


150 


PL'I,.M()NARY    rrOERCULOSIS    OK     CONSITMI'TION 


Palpation  shows  increased  fremitus  except,  as  noU-d  in  lirst  stage, 
where  pleurisy  has  resulted  in  thickening.     The  skin  is  hot  and  dry. 

Percussion  .shows  posit ivr  dullness  over  the  affected  areas,  which 
contrasts  markedly  with  tlic  nn;itVected  parts  where  the  respiration  is 
augmented  luid  tlir  iiolr   pii'lci-ii;\tur;illy  clear.     Roth  apices  may  be 


Fig.  38 — Showing  relation  of  lobes  to  posterior  chest  wall,  also  extension  of 
tuberculous  lesion  (Patton).  A  Primary  lesion.  B  Extension  of  primary 
lesion.     CC  Secondary  deposits. 

affected.  The  plexor  finger  notes  increa.sed  resistance.  Pain  011  per- 
cussion is  often  complained  of.  Hard,  board-like  tympany  is  not 
encountered  in  recent  cases  but  is  found  in  old  chronic  cases  with 
extensive  fibroid  changes.  Caseous  consolidation,  as  noted  under 
pneumonic  phthisis,  has  a  tubular  or  bronchial  quality.  Percussion 
should  be  practised  in  the  supraspinous  fossic  and  in  the  inti-ascapular 
regions,  for  reasons  already  given.  In  muscular  and  fleshy  people  not 
nuich  infoi'mation  may  be  gained  thereby,  but  in  thin,  and  especially 


PULMONARY    TUBERCULOSIS    OR    CONSUMPTION  151 

in  emaciated  individuals,  the  returns  are  of  great  value.  Myoidema 
is  the  name  given  to  the  local  contraction  and  bulging  of  the  muscles, 
when  subject  to  irritation,  such  as  occurs  in  direct  pereusbion  of  the 
pectorals.  It  is  encountered  in  thin,  nervous  individuals,  and,  al- 
though often  seen  in  phthisis,  is  not  of  any  special  significance. 

Auscultation.  Vocal  resonance  is  increased.  The  breath  sounds 
are  harsh. 

The  disappearance  of  the  vesicular  elements  and  the  approach 
toward  pure  bronchial  breathing  are  in  direct  proportion  to  the 
amount  of  consolidation.  The  inspiratory  portion  of  the  sound  is 
shortened  and  the  expiratory  part  is  prolonged  and  blowing.  When 
consolidation  surrounds  a  bronchial  tube,  typical  blowing  respiration 
obtains.  The  signs  are  apparent  in  the  supraspinous  fossnj  as  well 
as  in  front.  Bronchophony,  a  high  degree  of  vocal  resonance,  may 
be  present.  It  denotes  consolidation.  The  presence  of  pleurisies  may 
give  rise  to  fine  superficial  friction  sounds  or  cracklings,  and  extensive 
bronchitis  may,  by  its  noisy  signs,  interfere  with  auscultation. 

Acquired  lesions  of  the  cardiac  valves  are  certainly  rarely  encoun- 
tered in  the  sub.jects  of  pulmonary  tuberculosis,  especially  in  the 
chronic  forms  of  the  disea.se :  so  rarely,  indeed,  that  the  late  Henry 
Formad  denied  their  existence. 

As  pointed  out,  however,  under  the  caption  Congenital  Cardiac 
Defects,  the  subjects  of  congenital  valvular  lesions  are  very  prone  to 
acquire  pulmonary  tuberculosis. 

THIRD  STAGE.    SOFTENING  STAGE.    CAVITY  FORMATION. 

During  this  stage  a  portion  of  the  lung  is  undergoing  softening 
while  in  other  portions  consolidation  is  proceeding  by  reason  of  con- 
tinued infiltration.  Hence  the  signs  vary.  The  persistence  of  moist 
rales  and  cracklings  in  areas  prciviously  consolidated  indicates  soft- 
ening. 

Inspection.  Hectic  has  increased.  Alternate  hot,  dry  skin  and 
cold,  clammy  perspiration  are  noted.  Emaciation  has  made  marked 
encroachments.  The  limitations  of  movement  during  respiration  are 
still  more  restricted  and  the  flattening  under  the  clavicles  more  pro- 
nounced than  in  the  earlier  stages.  The  superficial  veins  over  the 
thorax  attract  attention  by  their  prominence  and  fullness.  Tyson 
draws  attention  to  upward  retraction  of  the  heart  in  cases  involving 
the  left  upper  lobe.    It  must  be  rare.     He  also  notes  that  the  area  of 


152  I'Ul.MONAKV    TrBKI{CL"U>SIS    UK     fONs^UMrTluN 

cardiac  impulse  enlarges  upwards  and  pulsation  may  l)e  visible  in  the 
third  and  fourth  left  interspaces. 

Palpation.  Vocal  fremitus  is  still  increased  in  spite  of  cavity, 
since  cavities  form  in  the  midst  of  consolidated  areas  and  are  sur- 
rounded by  compact  substance  which  increases  conduction.  Osier 
remarks,  "In  the  later  stages,  when  cavities  form,  the  tactile  fremitus 
is  usuall}'  much  exaggerated  over  them."  But  considerable  thick- 
ening of  the  pleura  diminishes  this  fremitus.  If  air  cannot  get  into 
a  cavity  by  reason  of  its  bronchus  being  closed,  the  fremitus  is  not 
increased.    Rhonchial  fremitus  may  be  present. 

Percussion  over  cavities  gives  neither  as  positive  nor  as  unvary- 
ing results  as  over  consolidation.  If  the  cavity  wall  be  thick  and  the 
substance  between  it  and  the  surface  dense,  the  percussion  note  will 
be  dull  as  in  consolidation,  though  heavier  percussion  may  elicit 
tympany.  If  dense,  but  thinner  walls  intervene,  the  sound  is  a  mix- 
ture of  dullness  and  tjnnpany,  difficult  to  describe.  Very  thin  walls 
yield  sounds  which  are  truly  tympanitic  or  metallic.  Amphoric  and 
cracked-pot  sounds  often  may  be  elicited.  To  demonstrate  the  cracked- 
pot  sound,  percuss  with  a  firm,  quick  stroke,  while  the  patient  with 
suspended  respiration,  holds  the  mouth  open.  If  a  cavity  undei'lies  a 
layer  of  healthy  tissue,  which  would  be  a  seemingly  rare  condition, 
the  note  is  clear,  especially  on  light  percussion.  Pei"cu.ssion  sounds 
are  much  modified  in  the  presence  of  cavities  by  the  act  being  per- 
formed with  the  mouth  alternately  opened  or  closed.  With  the  mouth 
closed,  the  pitch  is  lowered  and  the  vibrations  longer.  This  is  known 
as  Wintrich's  changed  note.  Da  Costa  points  out  that  over  cavities 
the  heart  sounds  are  heard  with  extraordinary  clearness  and  that 
there  is  often  seen  a  "wavering  impulse"  in  the  second  intercostal 
space. 

AuscuIfatioH.  The  lireathing  sounds  vary  with  tfie  relative  de- 
gree of  consolidation  and  excavation.  Over  the  hardened  areas  we 
still  have  bronchial  sounds,  and  if  these  are  mixed  with  small  bub- 
blings  and  cracklings,  subcrepitant  rales,  it  indicates  liquefaction  or 
beginning  excavation.  Cavities  give  rise  to  new  .soiuids.  It  is  worthy 
of  note  that  numerous  small,  isolated  cavities  without  much  fibroid 
deposit  or  pleural  thickening,  may  exist  at  the  apex  and  yet  the  per- 
cussion note  remain  unaltered,  although  the  auscultatory  sounds  will 
be  greatly  modified  and  out  of  harmony  with  the  percussion  findings. 
Cavernous  breathing  describes  the  tidal  air  entering  and  leaving  an 


PULMONARY    TL^BERCULOSIS    OR    COXSUMPTIOK-  153 

excavation.  "When  the  walls  of  the  ea^•ity  are  firm  and  imj-ielding, 
the  note  of  respiratory  rhythm  is  higher  pitched,  metallic  and  echo- 
like. This  is  amphoric  breathing.  Large  bubbling  sounds  occur  when 
air  passes  into  a  cavitj-  partially  filled  with  liquid,  termed  gurgling 
rales.  Cavities  which  give  forth  the  amphoric  respiratory  sounds  wiU, 
when  the.v  contain  liquid,  produce  metallic  tinkling. 

The  voice  sounds  as  modified  by  cavities,  are  interesting  and  dis- 
tinctive. Cavernoiis  voice,  like  cavernous  breathing,  is  the  hollow,, 
resonant  quality  imparted  to  the  soimd  by  reason  of  its  traversing 
an  excavation.  Amphoric  voice  has  added  thereto  an  echoing,  metallic 
or  musical  quality,  and  is  higher  in  pitch  than  the  cavernous  voice. 
Pectoriloquy,  both  spoken  and  whispered,  when  present  is  a  distinctive 
sign  of  cavitj-.  The  term  has  already  been  defined.  In  apical  cavities 
the  heart  sounds  are  often  distinctly  heard  and  occasionally  an  in- 
tense systolic  murmur  is  transmitted  into  the  cavity.  Over  left  apical 
cavities,  gurgling  sounds  or  crackling  sounds,  sjTichronous  with  the 
heart  impulse,  may  be  heard.  They  are  caused  by  an  impact  com- 
municated to  a  cavity  partially  filled  with  fluid.  Walsh  describes  a 
ease  in  which  the  suceussion  splash  was  obtainable,  as  described  under 
pneumothorax. 

AUXILIARY  SIGNS  OF  PHTHISIS. 

Fever.  The  deposition  of  tubercles  is  accompanied  by  elevation 
of  temperature,  hence  fever  is  an  early  and  characteristic  sign.  The 
maximum  is  between  two  and  six  P.  M.  Early  fever  is  generally 
remittent.  Later  both  intermittent  and  remittent  types  occur. 
Hectic,  which  is  in  realitj'  septic  fever,  due  to  the  absorption  of  tuber- 
culous products,  is  a  more  or  less  regular  rise  and  fall  of  temperature 
varying  between  wide  ranges,  rising  to  102° — 104°  and  falling  to  sub- 
normal, even  96°  being  not  unusual.  This  type  prevails  in  the  soft- 
ening and  cavity  formation  stage. 

Cough.  This  sjTnptom  has  already  been  touched  upon.  At  first 
so  slight  that  the  patient  will  deny  its  existence,  it  often  grows  to  be 
the  most  distressing  and  intolerable  of  the  symptoms,  causing  the 
patient  to  lose  sleep  or,  as  is  sometimes  the  ease,  exciting  intractable 
vomiting,  thus  contributing  to  the  rapid  emaciation  of  the  afflicted. 
Its  early  characteristic  is  hacking,  unaccompanied  by  expectoration; 
technically,  unproductive.  Then  a  glairy  mucus  is  coughed  up.  If" 
the  larjTix  is  involved  early  the  cough  as  well  as  the  voice  is  husky. 


154  ITI.MdXAKV    TUBERCULOSIS    OR    CONSUMPTION 

Spells  of  c'oiijrhiug  followed  by  copious  expectoration  deuote  cavities 
or  bronchiectasis.  Oftenest  such  paroxysms  occur  on  wakinj;;.  Some 
cases  progress  to  solidifii-ation  or  even  to  eavitics  with  veiy  little 
cough. 

Expectoration  follows  cough,  although  the  cough  may  have  i-e- 
mained  dry  for  a  long  period.  At  first  scanty,  it  increases  rapidly 
and  may  be  as  much  as  250  c.  c.  in  twenty-four  hours.  Sometimes 
distinct  apical  manifestations  or  extensive  consolidation  are  accom- 
panied with  insufficient  expectoi-ation  to  allow  of  an  examination.  The 
early  expectoration  is  glairy,  mucoid,  containing  sago-like  grains,  alve- 
olar cells  which  have  undergone  myelin  degeneration.  (Thudichuni.) 
Presently  grayisli  or  greenish  masses  are  observed  and  are  the  first 
differential  constituents  of  the  sputum.  They  should  be  examined 
microscopically.  After  this  the  expectoration  becomes  more  muco- 
purulent, may  he  blood-tinged.  The  nummular  masses  already 
described  arc  oi  frequent  occurrence,  and  are  distinctive  of  cavity 
formation.  Each  mass  is  separate,  greenish  or  gray-green  in  color, 
airless  and  sinks  to  the  bottom  of  the  cup  when  thrown  into  water. 
The  odor  of  the  sputum  is  sweetish,  mawkish,  unpleasant  Inil  not 
offensive.  The  sputum  contains  pus  corpuscles,  and  epithelium  IVnin 
the  entire  tract  traversed  by  the  aii- — the  mouth  to  the  alveoli.  The 
latter  cells  are  most  numerous.  Blood  discs,  particles  of  food,  oil 
drops,  elastic  tissue  fibers  and  bacilli  are  other  con.stituents. 

Elastic  fibers  are  derived  from  the  blood  vessels,  the  bi'onchi.  the 
alveoli  or  from  particles  of  ingested  food.  Rinsing  the  mouth  before 
collecting  the  sputa  will  obviate  a  mistake  as  to  food  tissue.  It  is  to 
be  remembered  that  such  tissue  may  be  retained  in  the  mouth  for 
several  days.  Boiling  the  picked-out  masses  with  liquor  potassa  or 
soda  in  a  test  tube  allows  the  elastic  tissue  to  fall  to  the  bottom  of  the 
tube,  when  it  may  be  examined  microscopically.  Osier  states  that  a 
method  quite  as  efficient  is  to  spread  the  masses  into  a  thin  layer 
between  two  glass  plates,  which  are  then  held  against  a  lilack  back- 
ground. The  elastic  tissue  shows  against  the  baekgroimd  as  opaque, 
grayish-yellow  spots,  which  may  be  immediately  examined  by  the  low 
power,  or  by  sliding  the  glasses  apart  may  be  picked  out  for  examina- 
tion on  a  slide.  He  states  that  milk  globules  and  fragments  of  bread 
are  similar  in  appearance,  but  that  the  eye  soon  learns  to  distinguish 
these.  Fibers  from  the  alveolar  walls  are  branched  or  wreath-like 
interlacements  and  show  the  arrangement  of  the  air-cells.    Those  from 


PULirOKAKT    TL-BERCULOSIS    OR    COXSUMPTIOX  155 

the  broncM  are  elongated  fibers,  two  or  three  together  and  form 
reticuli.  Those  from  the  artery  may  be  sheet-lite  or  fenestrated  mem- 
brane, as  though  it  were  the  intima  of  a  vessel.  (Jeuerally  they  resem- 
ble the  fibers  derived  from  the  bronchi.  Alveolar  fibers  indicate  exten- 
sive erosion,  softening  and  destruction.  Epithelial  cells  from  the 
alveoli  are  also  found.  These  are  large,  oval  or  round  non-nucleated 
cells  about  twice  the  size  of  a  pus  corpuscle. 

The  tubercle  bacilli  are  the  unfailing  sign  of  tuberculosis.  They 
are  made  apparent  only  by  special  staining  methods,  and  microscopic 
examination.  The  simplest  method  is  perhaps  the  following:  Shake 
up  commercial  aniline  oil  in  water  until  the  sohition  is  saturated. 
Filter  out  100  c.  c.  of  this  solution.  Xext  add  fuchsin  to  absolute 
alcohol  until  the  alcohol  is  saturated.  Add  11  c.  c.  of  the  second 
solution  to  the  100  e.  c.  of  the  first,  for  the  stain. 

Pick  out  a  small,  ehee.sy-looking  particle  of  sputum  with  a  needle 
and  spread  on  a  cover-glass  by  rubbing  against  a  second  glass.  Dry 
these  slowly  by  holding  a  foot  above  a  Bunsen  burner  (or  alcohol 
flame).  Cover  the  sUde  liberally  with  the  staining  fluid  and  hold 
near  the  flame  until  the  fluid  boils,  after  which  it  is  washed  in  run- 
ning water.  It  is  now  put  in  a  30  per  cent,  solution  of  nitric  acid 
until  decolorized,  when  it  is  again  washed,  mounted  and  examined. 

The  bacilli  are  colored  red  and  appear  as  elongated,  slightly- 
curved,  sometimes  beaded  rods.  In  doubtful  cases  the  covers  are 
allowed  to  remain  twenty-four  hours  in  the  stain.  The  niimber  varies 
from  a  full  field  to  one  or  two  found  only  on  repeated  examination. 

In  disputed  cases,  where  the  symptoms  are  not  confirmed  by  the 
microscopic  findings,  it  is  recommended  to  make  cultures  from  the 
sputum.    Directions  therefor  may  be  found  in  works  on  Baeteriolog}'. 

Hcemoptysis.  By  reason  of  the  frequency  with  which  it  occurs 
and  the  serious  results  which  attend  it  h;T?moptT.-sis  has  a  specially  im- 
portant relationship  to  pulmonaiy  tuberculosis.  Blood  may  simply 
occasionally  tinge  the  expectoration  or  it  may  be  present  in  the  sputa 
in  considerable  quantity.  It  occurs  early  and  late  in  the  disease  and 
is  more  frequent  in  males  than  in  females.  It  may  be  the  fii'st 
premonition  of  the  invasion  of  the  dread  destroyer,  or  it  may  close 
the  drama.  The  onset  of  the  attack  may  be  sudden  or  a  premonition 
of  its  oncoming  may  be  gathered  from  the  staining  of  the  sputa  which 
often  precedes  it  for  two  or  three  days.  It  may  come  on  during 
quiescence,  after  exercise,  after  a  fall  or  a  blow  iipon  the  chest.     The 


156  PULMONARY    TrUERCl'I-USlS    oK     C(  INSIMPTKIN 

idea  that  it  follows  sudden  exertion,  strain  or  excitement  is  not  borne 
out  by  clinical  experience.  In  many  cases  it  comes  on  during  sleep. 
In  a  proportion  of  the  subjects  both  physical  signs  of  the  disease 
and  bacilli  are  absent.  In  anotlier  proportion  bacilli  are  found  subse- 
quent to  haemorrhage.  In  the  third  class,  evidences  of  the  disea.se  are 
positive  and  bacilli  found  in  the  expectoration  confirm  the  signs. 

HaMuoptysis  should,  however,  always  excite  a  strong  suspicion  of 
tubercle  and  the  cases  subsequently  should  be  carefully  watched. 

Ilipmoptysis  occurs  in  sixty  or  eighty  per  cent,  of  all  eases  of 
pulmonary  tuberculosis.  The  amount  varies  from  a  teaspoonful  to  a 
pint,  being  smaller  when  it  occurs  early  in  the  disease.  Even  large 
hjemorrhages  ai-e  seldom  immediately  fatal.  In  character,  blood  from 
the  lungs  is  frothy,  mixed  with  mucus,  bright-red  in  color,  unless  it 
has  been  retained  in  a  cavity,  when  it  is  darker.  After  hiemorrhage 
the  sputa  may  contain  dark  masses  of  blood  or  may  be  blood-streaked 
for  several  days.  A  careful  examination  of  the  haMuorrhagic  mass 
often  reveals  small  mucous  nodules  in  which  bacilli  or  elastic  ti.ssue 
may  be  found. 

The  general  symptoms  accompanying  the  loss  of  blood  are  noted 
under  haemoptysis.  Some  of  the  special  symptoms  are  the  great  dis- 
turbance of  mental  balance  and  the  febrile  reaction,  lasting  from 
several  days  to  two  weeks,  which  succeeds  every  considerable  hemor- 
rhage. This  is  attributed  to  the  foci  of  broncho-pneumonia  arising 
from  the  luug  substance  derived  from  the  hajmorrhagic  cavity  which 
have  been  drawn  into  the  puhnonary  alveoli.  The  bleedings  may  be 
widely  separated  from  each  other  or  may  recur  at  frequent  intervals. 

Dyspnosa  is  not  increased  in  proportion  to  the  acceleration  of 
respiration,  and  is  not  marked  even  when  respirations  are  very  fre- 
quent. Eyspnoea  may  be  cardiac  by  reason  of  enlargenlent  of  the 
right  heart. 

Perspiration.  Drenching  perspirations  are  a  common  symptom. 
These  come  on  after  cavity  formation.  They  occur  after  the  fever 
drop  which  takes  place  towards  morning,  hence  the  familiar  term 
"night  sweats'".  They  may  occur  during  the  day.  Sometimes  they 
occur  in  the  early  stages  and  are  the  cause  of  the  patient  seeking 
the  doctor. 

The  pulse  is  soft  and  compressible,  though  quick  and  frequent. 
Venous  pulsation  and  capillary  pulsation  are  often  seen.  With  the 
progi-ess  of  the  disease  the   pulse   weakens.     Vomiting,   excited  by 


PULMON^VBT    TUBERCULOSIS    OR    CONSUMPTION  157 

coughing,  is  an  unpleasant  symptom  coming  ou  late  in  the  disease. 
Pain  either  is  due  to  coughing,  when  it  is  located  at  the  base  of  the 
sternum,  or  it  is  due  to  pleurisy,  when  it  is  located  over  the  lesion. 

Diarrhoea  is  one  of  the  late  symptoms.  When  once  established  it 
is  apt  to  prove  intractable. 

The  clubbing  of  the  fingers,  as  noted  by  Hippocrates,  comes  with 
the  advance  of  the  disease,  but  occurs  also  in  chronic  asthma,  bron- 
chitis, and  more  rarety  in  chronic  cardiac  diseases.  It  has  been  noted 
in  cases  of  aneiu-ysm.  The  finger-tips  become  bulbous  and  the  nails 
curve  over  the  finger  tips.  All  of  the  fingers  are  not  equally  aft'eeted. 
(See  Clubbing.) 

The  Urine  in  Tuberculosis.  The  quantity  of  urine  voided  is  influ- 
enced by  the  diaphoresis,  diarrhcea,  pyrexia  and  even  the  quantity  of 
expectoration.  Thirst,  which  accompanies  the  febrile  stage,  increases 
the  amoimt;  the  other  conditions  diminish  it.  It  may  be  as  little  as 
500  c.  c.  Uric  acid  and  the  sulphates  change  but  little.  Urea  dimin- 
ishes markedly  during  the  daily  febrile  period,  and  increases  in  the 
same  proportion  during  the  sweating  period.  It  often  settles  down  as 
a  pink  sediment.  Diarrhoea  diminishes  the  urates  here  as  in  other 
diarrheal  diseases.  The  amount  of  chlorides  varies  with  the  quantity 
of  food  ingested  and  the  incidental  complications. 

Ehrlich's  diazo-reaction  is  sometimes  obtainable.  Its  presence 
maj'  be  regarded  as  unfavorable.  It  is  apt  to  be  found  in  cases  which 
are  rapidly-progressing,  and  chronic  cases  which  are  nearing  the  end. 
A  trace  of  albumin  is  frequent,  but  casts,  blood  and  epithelium  are 
exceptional.  When  present  they  indicate  amyloid  changes.  If  pus 
occurs  in  the  urine  it  should  be  examined  for  bacilli. 

The  method  of  obtaining  the  diazo-reaction  is  desei'ibed  in  the 
section  on  Urine. 

State  of  the  Blood  in  Pulmonary  Tuberculosis.  Cabot*'  makes 
the  following  statements: 

1.  The  red  corpuscles  are  usually  normal,  but  the  hemoglobin 
is  diminished.    In  some  cases  both  ai'e  diminished. 

2.  The  leucocytes  do  not  change  in  character. 

3.  In  the  early  stages  of  the  disease  the  white  corpuscles  are 
normal,  after  an  attack  of  hfemoptysis  they  show  an  increase. 

*Ycar-Book   of  Treatment,  1897. 


loS  PULMONARY     TUBERCULOSIS     OR     CONSUMPTION 

4.  If  cavities  are  present  there  is  no  leiieoeytosis.  If  the 
leucocytes  are  increased,  there  are  no  cavities. 

5.  Pneumonic  tuberculosis  (extensive  infiltration  i  may  show- 
marked  leueocytosis.  not  invariably. 

6.  Fibroid  tuberculosis  shows  no  leueocytosis. 

7.  Pyrexia,  due  to  the  presence  of  pyofrenic  orirauisnis.  shows 
leucocyte  increase.  If  not,  there  is  no  leueocytosis.  If  fever  is  absent 
there  is  no  leucoc\'tosis. 

In  contradiction  to  the  fourth  statement,  which  wouhl  he  most 
important  if  confirmed.  Stein  and  Erhmann  state  that  one  of  the 
conditions  of  leueocytosis  in  pulmonary  tuberculosis  is  the  presence 
of  cavities  in  the  lungs,  hence  at  present  no  definite  conclusions  can 
be  reached  on  this  point. 


SECTION  IX. 

THE  HEART. 

fhysioloyij.  The  heart  is  a  double-cylinder  muscular  pump.  Be- 
tween the  two  cylinders  no  communication  exists  after  birth.  One  side 
serves  for  the  low  service  or  pulmonary  circulation,  the  other  for  the 
high  service  or  systemic  circulation.  Each  pi^mp  consists  of  two  cham- 
bers, the  receiving  chamber  or  auricle,  and  the  pumping  chamber  or 
ventricle.  As  soon  as  the  auricles  are  filled  they  contract,  forcing  the 
blood  into  the  ventricles,  the  contraction  of  which  immediately  follows. 
After  the  ventricular  contraction  a  period  of  rest  succeeds. 

The  contraction  of  the  cavities  of  the  heart  is  called  the  cardiac 
systole,  the  period  of  rest  is  called  the  diastole,  the  two  periods  make 
up  the  cardiac  cycle. 

The  systole  of  the  corresponding  cavities  of  the  two  sides  of  the 
heart  is  exactly  synchronous,  that  is  to  say,  the  two  auricles  contract 
simiiltaneously ;  and  the  simultaneous  contraction  of  the  ventricles 
immediately  follows  that  of  the  auricles.  While  the  auricles  are  con- 
tracting the  ventricles  are  in  a  state  of  relaxation,  and  the  relaxation 
of  the  auricles  commences  directly  after  the  ventricular  contraction 
begins. 

The  rate  of  the  heart  beat  depends  upon  the  duration  of  the  dias- 
tolic pause,  which  lessens  proportionally  as  the  heart  beats  more 
rapidly. 

Anatomic  Relations.  Encased  in  the  pericardial  sac,  suspended 
apex  downward  from  the  great  vessels,  the  heart  largely  occupies  the 
middle  mediastinum  or  interpleural  space.  It  hangs  obliquely  behind 
the  lower  two-thirds  of  the  sternum,  projecting  slightly  to  the  right 
and  considerably  to  the  left  of  that  bone. 

That  the  heart  is  suspended  by  its  vessels'  and  not  supported  by 
the  diaphragm  is  proved  by  the  fact  that  the  diaphragm  separates  from 
the  heart  during  deep  inspiration,  as  shown  b^'  the  Rontgen  rays. 

Furthermore,  the  ravs  show  that  the  heart  chambers  are  not  en- 


161)  THE    HEART 

tiix4y  emptied  at  each  systole,  as  was  formerly  assumed  by  physiolo- 
gists- (Beckj. 

Behind,  its  base  corresponds  to  the  sixth,  seventh  and  eighth 
thoracic  vertebra;,  from  which  it  is  separated  by  the  oesophagus  and 
the  aorta.  In  front,  the  base  corresponds  to  a  line  drawn  across  the 
sternum  at  the  lower  border  of  the  second  costal  cartilage,  extending 
one-half  inch  to  the  right  and  one  inch  to  the  left  of  the  sternixm.  Its 
lower  border,  made  up  of  tlie  right  ventricle,  is  nearly  horizontal.  It 
rests  lightly  on  the  central  tendon  of  the  diaphragm,  which  separates 
it  from  the  convex  surface  of  the  liver.  The  apex,  which  possesses  a 
certain  freedom  of  motion,  strikes  the  chest  wall  at  a  point  between  the 
cartilages  of  the  fifth  and  sixth  ribs,  at  a  point  two  inches  below,  one 
inch  to  the  sternal  side  of  the  nipple,  which  point  is  314  to  3I/2  inches 
from  the  midsternum  in  the  fifth  interspace.  The  right  ventricle  is 
anterior  and  lies  directly  under  the  sternum.  Its  lower  scgme'nt  occu- 
pies the  fifth  interspace,  its  lower  border  is  on  a  level  with  the  sixth 
cartilage.  The  organ  projects  slightly  to  the  right,  but  considerably  to 
the  left  of  the  breast  bone. 

The  left  ventricle  lies  chiefly  behind  the  right,  but  its  left  border, 
which  includes  the  apex,  comes  to  the  front  in  systole.  This  Ijorder  lies 
wholly  within  the  nipple  line. 

Perhaps  DaCosta  was  the  first  to  say  that  the  heart  of  an  individ- 
ual is  about  the  size  of  his  fist.  Roughly  speaking,  the  comparison  is 
fairly  correct  and  useful.  Cunningham  gives  the  average  weight  of 
the  heart  in  adult  males  as  eleven  ounces  (310  grams),  in  females  nine 
■ounces  (250  grams). 

Tlie  Valves  of  the  Heart.  Each  side  of  the  heart  is  equipped  with 
two  valves.  One  guards  the  opening  between  the  two  chambers,  the 
auricle  and  its  corresponding  ventricle,  the  other,  placed  within  the 
venti'icle,  closes  the  aperture  of  the  great  vessel  which  springs  there- 
from, viz : — the  aorta  on  the  left  and  the  pulmonary  artery  on  the  right 
•side.  Three  of  these  valves  are  made  up  of  three  cusps,  or  leaflets, 
•each,  while  the  remaining  one  consists  of  only  two  cusps.  This  latter, 
named  the  wifral  valve,  closes  the  orifice  between  the  left  ventricle  and 
its  auricle.  To  the  free  edges  of  its  leaflets  are  attached  the  chorcke 
tendinece. 

The  corresponding  opening  on  the  right  side,  that  between  the 
right  ventricle  and  its  auricle,  is  closed  by  the  tricuspid  valve,  com- 


2 

> 

rr. 


THE    HEART  161 

posed  of  three  leaflets  as  its  name  indicates.  Its  movements  are  also 
limited  by  the  chordae  tendinea;. 

The  aortic  and  the  pulmonarj^  valves  close  each  their  respective 
openings.  Each  is  composed  of  three  cusps  or  concave  pockets  whose 
edges  are  free.  They  are  named  respectively,  the  aortic  semilunar  and 
the  pulmonary  semilunar  valves. 

The  Prcecordium.  That  portion  of  the  thoracic  wall  which  covers 
the  heart  is  called  the  precordial  region.  It  is  roughly  quadrilateral, 
and  its  boundaries  are  a  vertical  line  drawn  %ths  of  an  inch  to  the 
right  of  the  sternum,  another  parallel  thereto  passing  just  out- 
side the  apex,  two  horizontal  lines,  the  first  drawn  through  the  junc- 
tion of  the  manubrium  with  the  gladiolus  of  the  sternum  (second  rib), 
the  second  passing  through  the  ensiform  cartilage. 

THE  EXAMINATION  OF  THE  HEART. 

The  method  adopted  for  the  examination  of  the  lungs  applies 
equally  to  the  heart,  and  the  same  order  should  be  observed,  namely, 
the  history  of  the  case  should  be  followed  by  inspection,  palpation, 
mensiu'ation,  percussion  and  auscultation. 

History.  Much  diagnostic  aid  is  derived  from  the  history  of  the 
•case,  since  many  symptoms  point  unmistakably  to  cardiac  lesions.  Es- 
pecially the  date  of  previous  diseases,  which  may  have  stood  in  a  causa- 
tive relation,  should  be  fixed  and  their  nature  carefully  inquired  into. 

When  the  condition  of  the  patient  admits  the  standing  position  is 
the  most  advantageous  for  the  examiner,  who  may  himself  either  stand 
or  be  seated  on  a  rather  high  chair.  He  thus  avoids  the  humming 
noise  arising  from  his  own  circulation,  which  is  a  fruitful  source  of 
annoyance  to  the  examiner  when  he  is  obliged  to  assume  a  stooping 
posture. 

Even  bearing  in  mind  the  possibility  of  being  accused  of  prolixity 
we  urge  upon  the  student  the  desirability  of  taking  advantage  of  every 
reasonable  opportunity  to  examine  the  normal  heart  with  all  the  com- 
pleteness of  detail  which  would  be  used  were  the  organ  diseased. 
While  percussion  and  auscultation  are  relatively  the  most  important 
steps,  the  others  are  by  no  means  to  be  neglected. 

Inspection.  We  begin  our  inspection  by  noting  the  contour  of 
the  chest  wall.  In  health  the  two  sides  are  symmetrical  or  nearly  so, 
but  this  symmetry  may  be  gravely  altered  by  disease.  Occasionally 
we  may  detect  a  slight  prominence  or  even  protrusion  over  the  seat  of 


11)2  TIIF.    IIKART 

tliL'  heart  in  pcrrt'ctly  la'allhy  pcr.suiis,  ospocially  Ihoso  who  practise 
habitually  great  physical  exertion.  Hypertrophy,  or  the  accumula- 
tion of  rtuid  within  the  pericardinni.  markedly  emphasizes  this  prom- 
inence. Pericardial  inflammation  may  k'ave  as  a  sequence  a  very 
evident  pra^cordial  deiircssion.  \Ve  note  the  condition  of  the  circu- 
lation, as  manifested  li.\'  the  eapiHaries.  the  preseiiee  oi-  alisenee  of 
(pdenia  about  the  eyes  or  anlvles  as  evinced  iiy  pitting,  the  presence 
and  character  of  the  cough,  the  number  and  character  of  the  i-espira- 
tions  and  the  amount  of  dyspiicea.  One  often  notes  a  peculiar  anx- 
ious expression  of  the  countenance  accompanying  certain  heart  lesions, 
which  is  most  impressive,  and  not  without  significance. 

The  most  important  particular  of  inspection  is  the  location  of 
the  apex.  It  is  usually  possible  to  recognize  the  apex  beat  by  inspec- 
tion, except  in  stout  persons  or  in  cases  where  the  organ  is  retracted 
from  the  chest  wall.  Sometimes  its  absence  is  accounted  for  by  its 
striking  against  a  rib,  instead  of  in  an  interspace.  The  impact  is  less 
apparent  in  women  than  in  men,  even  when  the  mamma  is  retracted. 
It  is  more  pronounced  in  spare  individuals  and  in  cases  in  which  the 
organ  is  hypertrophietl. 

The  location  of  the  imimlse  has  been  given  already  as  lying  be- 
tween the  fifth  and  sixth  ribs  at  an  average  distance  of  three  inches 
to  the  left  of  the  mesial  line.  In  narrow-chested  individuals  it  may 
be  lower  and  in  children  it  is  often  an  interspace  higher.  In  case  the 
impulse  is  invisible  it  may  be  bi-ought  into  view  by  causing  the  patient 
to  walk  briskly  a  score  of  paces,  by  bending  him  forward,  or,  if  re- 
cumbent, by  turning  him  M'ell  towards  his  left  front. 

Inspection  should  note  not  only  the  position  of  the  apex  beat,  but 
its  area,  whether  it  be  diffused  or  concentrated  and  the  regularity  of 
the  succession.  In  health  the  area  should  not  exceed  one  square  inch. 
The  location  of  the  impact  changes  only  slightly  in  the  different  posi- 
tions assumed  by  the  patient,  but  is  less  pronounced  when  the  person  is 
supine,  and  it  moves  slightly  to  the  left  when  he  lies  on  that  side.  It 
is  somewhat  altered  by  distention  of  the  stomach  and  by  flatulence.  It 
is  more  influenced  by  breathing.  During  deep  inspiration  the  heart 
descends,  the  forward  movement  of  the  expanding  left  lung  pushes  it 
backwards  and  to  the  right,  causing  the  apex  to  move  towards  the 
epigastrium.  During  forced  expiration  the  heart  descends  and  ap- 
proaches the  chest  wall,  a  larger  portion  of  its  anterior  surface  is  un- 
covered, the  impact  is  more  diffused  and  weightier:  hence  expiration 


PoSTERl 


LEFTVEN^fiiCLe, 


PosV 

floRTICCUSP 
^Wn  CUSpOF 

TRICUSPID 
Rl6fT    cusp 

— Ws-rfERioR  coip 

OF  TjllCt>5,PlO. 

/  RlWT  Vt/JTRrcLE. 


PLATE  VI. 


The  Valves  of  the  Heart,  their  Leaflets  and  Relative  Positions.  (After  Murray.) 
The  outer  line  represents  the  heart  in  diastole,  according  to  Spaiteholz. 


THE    HEART  163" 

offers  the  most  favorable  time  both  for  observation  and  for  ausculta- 
tion of  this  portion  of  the  organ.  Exercise  and  emotion  render  the 
impulse  more  distinct :  wasting  and  debilitating  diseases,  degenerations- 
and  anemias  lessen  it. 

Not  only  do  we  mark  the  location  of  the  apex,  but  we  search 
carefully  for  pulsations  in  other  regions,  especially  in  the  epigastrium 
and  over  the  area  of  the  right  ventricle.  The  pulsations  of  the  right 
ventricle  are  not  visible  in  health,  but  are  brought  out  by  violent  ex- 
ercise, and  diseased  conditions  similar  to  those  mentioned  as  affecting 
the  left  ventricle  may  cause  a  permanent  visible  impact.  The  pres- 
ence and  character  of  this  impact  should  be  noted  carefully,  as  in 
disease  it  is  of  considerable  diagno.stic  value.  Holding  the  breath  until 
one  begins  to  experience  a  sense  of  suffocation  will  bring  about  a  con- 
dition exactly  simulating  hypertrophy  of  the  right  ventricle.  The 
apex  beat  will  disappear,  and  the  impact  of  the  right  ventricle  will  be 
seen  plainly  in  the  epigastric  area.  Breathing  being  re-established 
order  is  quickly  restored.  Pulsations,  arterial  or  venous,  are  often 
seen  at  the  root  of  the  neck  and  in  the  abdominal  regions. 

CHANGES  IN  THE  POSITION  OF  THE  HEART,  THE  RESULT 
OF  DISEASE. 

A  pericardial  eft'usion  pushes  the  heart  upward  and  obscures  the 
apex  beat.  Even  a  slight  degree  of  emi^hysema  renders  it  invisible;. 
Enlargements  of  the  liver  tilt  the  heart  upward  and  outward.  Hyper- 
trophy of  the  right  ventricle  prevents  the  apex  from  striking  against 
the  chest  wall,  hence  rendering  it  invisible.  In  cases  where- 
there  have  been  previous  attacks  of  pericarditis  with  the  formation: 
of  adhesions  the  heart  systole  may  cause  at  each  stroke  a  more  or  less 
extensive  retraction  of  the  chest  wall  over  the  apex  region,  varying 
with  the  extent  of  the  attachments.  In  children  the  whole  prtecordia 
may  be  yielding.  In  very  extensive  hypertrophy  of  the  left  ventricle 
the  apex  beat  may  be  pushed  downward  and  to  the  left,  appearing  in' 
the  sixth,  seventh,  or  even  the  eighth,  interspace,  and  several  inches: 
outside  the  nipple  line,  as  occurs  in  the  so-called  cor  bovinum.  In' 
slighter  degrees  of  hypertrophy  the  area  of  impulse  is  displaced"  to- 
the  left  in  proportion  to  the  extent  of  the  change.  Dilata-tion  in- 
creases the  area  of  pulsation  and  renders  it  more  diffused"  without 
causing  much  displacement.  In  dilatation  and  fatty  degeneration  the- 
impact  is  weakened :  in  hypertrophy  it  is  strong  and  heaving. 


1(J4  rilK    IlEAKT 


INSPECTION. 


I'jiirdrd  l>isi)l(i((  nicnls  of  t\w  apex  are  ofti'ii  llu'  result  of  dis- 
eases bek>w  the  diapliraKiii  ea'usintr  pressure  ujiou  that  struetui-e. 
Such  are  solid  and  cystic  irrowths  of  the  abdoiuiiial  organs,  aseites  anil, 
to  a  lesser  deirree.  tympanites.  '1  he  upward  draiziiin;^  of  the  heart 
whicli  results  from  phthisical  contrai-tious  of  tiie  left  luun-  is  dcserii)ed 
under  Pidmonary  Tuberculosis. 

Collections  of  air  and  fluids  in  the  pleural  cavity  air  iui|ioitant 
■cau.ses  of  displacement  of  the  heart.  Occurring;  on  the  riyht  .side,  they 
are  less  potent  than  when  found  on  the  left.  A  larjie  left-sided  effu- 
sion may  so  displace  the  heart  that  the  impulse  is  .seen  on  the  right 
of  the  sternum,  even  under  the  rip:ht  nipple.  It  nuist  be  understood 
that  the  visible  impulse  in  such  cases  does  iiol  correspond  to  the  apcr. 
but  to  some  portion  of  the  right  ventricle  which  impinges  again.st  the 
thoracic  wall.  This  condition  has  received  the  name  of  drxiocardia. 
Adhesions  may  cause  the  displacement  to  become  permanent.  Such 
a  pulsation  should  not  be  confounded  with  that  resulting  from  hyper- 
trophy of  the  right  heart,  already  mentioned,  which  occurs  without 
displacement  of  the  apex,  although  the  apex  beat  may  be  invisible. 
In  some  cases  of  considerable  hypertrophy  of  the  right  heart  a  widely 
diffused  pulsation  or  heaving  is  seen  over  the  entire  epigastrium.  It 
results  from  the  exaggerated  impulses  communicated  to  the  left  lobe 
<of  the  liver.  It  should  be  distinguished  from  similar  pulsati(ms  com- 
municated to  the  liver  by  the  aorta,  which  can  usually  be  done  by 
timing  the  stroke  with  the  fingers  pushed  under  the  edges  of  the  ribs, 
where  the  heart  contractions  often  may  be  felt.  The  aortic  contraction 
is  slightly  later  in  point  of  time.  In  rare  cases  a  pulsation  is  seen  to 
the  left  of  the  sternum,  at  about  the  second  intercostal  space,  which 
point  corresponds  to  the  root  of  the  pulmonary  vessel.  Its  area  is 
limited,  and  on  palpation  a  sudden,  snapping  recoil  is  felt  to  succeed 
the  dilatation.  The  expansion  is  caused  by  the  filling  of  the  pulmon- 
:ary  vessel;  the  recoil  by  the  closure  of  the  semilunar  valves.  This 
condition  occurs  in  cases  of  pulmonary  phthisis  in  which  there  is  ad- 
vanced emaciation  associated  with  a  very  considerable  retraction  of 
the  left  lung,  and  is  comparatively  infrequent. 

Pulsation  at  the  Root  of  the  Neek,  when  seen  in  the  supra-sternal 
notch,  usually  means  aneurysm  or  dilatation,  either  of  the  aorta,  which 
curves  backwards  less  than  an  inch  below  the  uppei'  edge  of  the  manu- 


THE    HEART 


165 


brium,  or  of  the  innominate  vessel,  which  approaches  the  median  line 
behind  the  top  of  that  bone.  Farther  to  the  side  lie  the  innominate 
veins:  the  left  innominate  vein  traverses  the  root  of  the  neck  imme- 
diately below  the  sterno-cla-s-icular  junction,  and  often  receives  trans- 
mitted pulsations  from  the  arteries.  The  jugular  veins  are  frequently 
the  seat  of  pulsations,  either  venous  or  transmitted.  Venoiis  pulsa- 
tion is  present  in  valvular  disease  of.  the  right  side  of  the  heart.  The 
condition,  however,  occurs  independently  of  such  disease  and  simply 
indicates  venous  regurgitation,  with  inefficiency  of  the  valves  within- 
the  veins,  since  a  certain  amount  of  regurgitation  into  the  cavfe  is 
physiologic.  Venous  pulsation  is  irregular  and  wave-like,  and  can  be 
distinguished  readily  from  the  rise  and  fall  of  transmitted  pulsations 
by  making  just  sufficient  pressure  on  the  proximal  side  of  the  pulsa- 
tion to  obliterate  the  vein.  Transmitted  pulsations  continue  while  the 
venous  throb  disappears. 

Some  of  the  phenomena  just  described  are  not  wholly  apparent 
to  unaided  inspection  as  they  require  additional  diagnostic  processes 
for  their  appreciation,  but  owing  to  their  intimate  relationship  it 
seems  simplest  to  group  them  together. 

PALPATION. 

Palpation  for  the  most  part  confirms  inspection,  but  the  touch 
distinguishes  some  phenomena  which  are  invisible.  To  elaborate  all 
the  conditions  would  be  repetition. 

The  diversified  alterations  in  the  character  and  force  of  the 
heart's  impulse  are  more  readily  appreciated  by  palpation  than  by 
inspection.  An  impulse  can  be  felt  which  cannot  be  seen,  and  by  touch 
its  point  of  greatest  intensity  is  more  accurately  fixed.  We  study 
changes  in  the  rhji;hm  and  force  of  the  beat,  its  character,  its  extent, 
and  the  presence  of  abnormal  pulsations. 

Temporary  changes  of  both  rhj-thm  and  force  are  produced  by  ex- 
citement, emotion,  exercises  or  by  hysteria.  Permanent  alterations 
are  caused  by  hypertrophy,  which  increases  the  force  of  the  impulse, 
and  by  dilatation,  which  enfeebles  it  while  it  increases  its  area.  Mor- 
bid conditions  which  induce  softening,  such  as  acute  infectious  dis- 
eases, and  general  febrile  states,  enfeeble  the  impiilse.  Valvular  dis- 
eases, adhesions,  and  displacements  alter  permanently  the  character 
as  well  as  the  position  of  the  beat. 

Effusion  into  the  pericardial  sac  enfeebles,  obscures  or  obliterates 


166  THE    HEART 

the  impact,  and  if  iHTcepliljIc  it  may  liave  an  irix'iiiilai'.  wavy  i-liai'ac- 
ter. 

Reduplication  of  the  systole  indicates  pericai-dial  adhesions. 

Fremitus  and  a  peculiar  thrill,  likened  by  Laennee  to  the  purr  of 
a  eat.  are  sometimes  noticeable.  Both  of  these  phenomena  are  inter- 
estinii.  The  first,  pericardial  friction  fremitus,  may  be  felt  at  any 
point  over  the  jjrivcordial  region  in  pericarditis.  It  is  due  to  the  rub- 
bing together  of  the  two  roughened  pericardial  surfaces.  It  is  super- 
ficial, and  its  character  is  harsh,  rubbing  or  grating.  The  second,  "the 
purring  tremor  of  Laennee,"  is  felt  only  at  the  apex  or  at  the  base, 
and  is  associated  with  valvular  lesions.  At  the  apex  it  is  most  charac- 
teristic when  associated  with  mitral  stenosis.  The  purr  is  then  pre- 
.systolie.  but  it  may  be  present  in  roughening  of  the  valves  with  I'egur- 
gitation.     i  It  is  further  discussed  under  lesions  of  the  valves.) 

At  the  ba.se  it  is  indicative  of  aortic  valvular  disease,  oi-  of  an- 
eurysm of  the  first  part  of  the  arch. 

Congenital  stenosis  of  the  luiinionary  valve  is  said  to  be  associated 
with  a  similar  tremor. 

The  sphygmograph  and  the  cardiograph  are  niechanieal  aids  to 
jialpation  which  will  be  described  later. 

PERCrSSIOX. 

By  percussion  we  estimate  the  size  of  the  heart  as  a  whole,  and 
the  extent  of  the  part  of  the  organ  which  is  uncovered  by  the  lung. 
In  an  examination  it  is  helpful  and  convenient  to  outline  our  results 
upon  the  chest  with  an  aniline  pencil.  While  such  a  diagram  made 
by  two  examiners  would  be  apt  to  vary,  yet  each  might,  none  the  less, 
draw  correct  inferences  therefrom.  If  it  is  desired  to  ascertain  the 
area  of  relative  dullness,  or  that  area  which  most  nearly  coincides 
with  the  true  outline  of  the  heart,  then  strong,  firm  percussion  is 
employed :  whereas  if  it  is  desired  to  ascertain  the  area  of  absolute 
dullness,  which  most  nearly  coincides  with  the  uncovered  area,  then 
the  slightest  possible  stroke  is  used.  Since  in  expiration  the  heart  ap- 
proaches the  chest  wall,  advantage  should  be  taken  of  this  for  the  de- 
termination of  its  size,  but  in  outlining  the  uncovered  area  it  should 
he  borne  in  mind  that  the  object  of  the  examination  is  not  to  ascertain 
how  much  of  the  heart  the  patient  may  clear  by  pulmonary  gymnas- 
tics, but  to  ascertain  the  existing  conditions:  hence  the  percus.sion 
.should  be  made  during  (piiet  respiration.    To  obtain  accurate  results  in 


THE    HEART  167 

either  case  is  by  no  means  simple.  The  thin  edge  of  the  king  overlying 
the  denser  organ  beneath  so  modifies  the  note  that  mnch  confusion 
arises;  but  patience  and  practice  bring  rewards.  Personally,  we  have 
found  that  the  most  satisfactory  mode  of  determining  the  larger  out- 
line is  to  strike  with  just  sufficient  force  to  bring  out  clearly  the  normal 
pulmonary  note,  and  to  observe  the  slightest  change  of  that  sound  as 
indicating  the  heart's  border. 

PERCUSSION  AREAS  OF  THE  HEART. 

The  thin,  free  edge  of  the  right  lung  extends  inwards  to  the  mid- 
dle of  the  sternum,  and  completely  covers  that  portion  of  the  heart 
which  lies  to  the  right  of  the  mid-sternal  line.  Owing  to  the  recedence 
of  the  left  lung  from  the  sternum,  along  the  lower  border  of  the  fourth 
costal  cartilage,  which  it  closely  follows,  an  irregiilar  triangular  area 
of  the  right  ventricle  is  exposed  as  follows:  base,  the  lower  border 
of  the  fourth  rib  outward  to  the  parasternal  line  (a  vertical  line 
drawn  parallel  to  the  mid-clavicular  line,  half  way  between  it  and 
the  mid-sternal  line).  The  perpendicular  of  the  triangle  is  the  left 
border  of  the  sternum.  The  third  side  is  a  line  drawn  through  the 
upper  portion  of  the  xyphoid  cartilage  and  passing  nearly,  if  not  quite, 
horizontally  outwards  to  the  parasternal  line,  or  to  the  apex.  Prac- 
tically it  is  very  difficult  to  map  oiit  the  third  side  of  this  area,  since 
it  is  continuous  with  the  upper  border  of  liver  dullness,  and  the  differ- 
entiation between  these  two  is  very  slight ;  but  it  may  be  said  that  the 
heart  note  lacks  the  absolute  flatness  elicited  by  percussion  over  the 
liver,  where  also  the  finger  encounters  a  greater  amount  of  resistance. 
Hence  in  percussing  from  below  upwards,  the  fall  in  pitch  and  the 
dminution  in  resistance  enables  one  to  say  that  the  heart  has  been 
reached.  The  method  is  sufficiently  accurate  for  all  practical  pur- 
poses. When  still  greater  exactness  is  required  auscultatory  percus- 
sion may  be  employed,  with  the  aid  of  the  Bowles  instrument,  whereby 
the  differences  above  set  down  are  brought  out  more  clearly.  The  com- 
pleted triangle  is  called  the  area  of  positive  cardiac  dullness.  Its 
dimensions  are,  base  2  inches  to  2%  inches  (6  cm.)  ;  perpendic- 
ular 2  inches  ( 5  cm. )  ;  hypothenuse  3^/2  inches  to  4  inches  ( 10  em. ) . 

Percussion  affords  the  surest  means  at  our  command  of  estimat- 
ing the  actual  size  of  the  heart,  but  it  will  be  gathered  from  what  has 
been  said  that  the  method  falls  short  of  perfection.    Hence,  the  area 


IfciS  THE    IIKART 

iis  iiuipiH'd  out  by  this  moans,  while  imlicatiiiK  .L;t'iu'i'ally  the  heart 
boundaries,  falls  within  its  actual  limits  owiny;  to  the  curvature  of 
the  orjian  and  its  consequent  recedence  from  the  nearly  tiat  surface  of 
the  chest,  just  as  Ihe  peripliery  of  a  sphei'e  recedes  from  a  jilaiie  on 
which  it  rests. 

We  begin  on  the  left  side,  in  the  second  interspace,  as  far  out- 
ward as  the  parasternal  line  and  percuss  downward  along  this  line 
until  a  change  of  the  note  tells  us  that  we  have  reached  the  left  upper 
margin  of  the  heart,  which  should  be  in  the  third  interspace.  We 
follow  this  line  of  dullness  inward  to  the  sternum  and  pencil  it  as 
the  base  line  of  the  organ.  Crossing  to  the  opposite  side  and  percuss-  • 
ing  from  right  to  left,  in  the  same  interspace,  we  obtain  our  relalivc 
dullness  at  the  right  border  of  the  sternum,  to  which  point  wc  continue 
our  base  line.  The  line  on  the  right  may  be  traced  downward  along 
the  right  edge  of  the  sternum  as  far  as  the  fifth  interspace.  From  the 
point  of  starting  the  left  boundary  line  passes  downward,  with  a  sliulit 
outward  curve,  to  the  apex.  The  lower  border  line  corresponds  to  the 
line  of  separation  of  the  heart  and  liver,  and  sufficient  has  already 
been  said  regarding  its  determination.  l<\>rced  expiration  enlarges  the 
boundaries  by  about  one-half  inch,  the  transverse  diameter  being  more 
affected  by  respiration  than  the  vertical. 

Tin  Area  of  Absolute  Dullness.  Hughes  Bennett  gives  the  dimen- 
sions of  this  area  as  indicated  by  the  smaller  figures  above  cited,  say- 
ing that  if  these  measurements  are  exceeded  the  heart  is  enlarged. 
He  places  the  normal  transverse  diameter  at  '2  inches.  This  is  cer- 
tainly too  small  for  well-developed  men.  1  have  found  that  even  the 
larger  area  is  often  exceeded  without  any  evidence  of  hypertrophy  be- 
ing evinced  by  the  cardiac  sounds  or  by  changes  in  the  arterial  tension. 

In  women,  owing  to  the  interference  of  the  mammary  gland,  and 
the  change  in  the  chest  contour  from  corset-wearing,  these  limits  are 
harder  to  define  and  are  subject  to  much  broader  variation  than  in 
men.  In  children,  careful  percussion  often  fails  to  outline  satisfac- 
torily either  the  area  of  relative  dullness  or  the  area  of  absolute  dull- 
ness. Even  when  the  latter  can  be  defined  its  dimensions  are  propor- 
tionately smaller  than  in  the  adult. 

CHANGES  IX  THE  AI?EA  OF   I'K.ECOUDIAL  DULLNESS. 
A  full  inspiration  diminishes  the  area  of  dullness  by  displacing 
the  heart  backwards  and  extending  the     hum'      forward.        Changes 


PLATE  Vn. 


Relationship  of  the  Cardiac  Area  to  the  Costal  Cartilages 
and  Sternum. 

RV.  Right  Ventricle.      LV.  Left  Ventricle.      RA.  Right  Auricle. 

LA.  Left  Auricle.        S.Vc.  Superior  Vena  Cava.  Ao.  Aorta. 

P.    Pulmonary   valve.       A.    Aortic  valve.       M.  Mitral   valve. 
T.  Tricuspid  valve. 

From  Cunningham's  Anatomy 
by  permission  of  Wm.  Wood  &  Co. 


THE    HEART  169- 

wrought  by  disease  are:  an  increase,  a  diminution,  or  a  displacement 
of  the  dull  area. 

Decrease  in  its  area  may  result  from  cardiac  atrophy  which  ac- 
companies all  protracted  febrile  and  wasting  diseases,  but  such  atro- 
phy is  generally  inappreciable.  The  more  usual  cause  of  decreased 
area  is  disease  of  the  lung — emphysema  being  the  chief  offender. 
Even  a  slight  degree  of  emphj'sema  affects  the  marginal  air-cells. 

Hypertrophy  of  the  heart  is  the  most  frequent  cause  of  increase 
in  the  prsecordial  area.  Hypertrophy  of  the  left  ventricle  enlarges 
the  area  outward,  to  the  left,  and  somewhat  downward,  so  that  the 
apex  beat  maj-  be  found  in  the  sixth  or  seventh  interspace.  Hyper- 
trophy' and  dilatation  of  the  right  side  increase  the  percussion  area 
to  the  right  of  the  sternum.  In  cases  of  hypertrophy  or  dilatation  of 
both  ventricles  the  transverse  distance  is  increased  on  both  sides  of 
the  bone. 

The  other  phenomena  accompanying  and  confirming  the  above 
condition  are  described  under  their  separate  heads. 

Effusions  into  the  pericardial  sac  produce  a  lateral  extension  of 
the  percussion  dullness,  but  therewith  is  a  cone-shaped  upward  pro- 
longation of  the  dull  area  towards  the  left  sterno-clavicular  junction. 
It  is  reiterated  that  hypertrophies  do  not  materially  increase  the  ver- 
tical area  of  dullness.  Effusions  impart  an  increased  sense  of  re- 
sistance on  percussion,  and  sometimes  there  is  a  filling  or  lifting  of 
the  prtBCordia  with  each  impact. 

Tumors  of  the  mediastinum  and  aneurysms  increase  the  dull 
area.  The  diagnosis  of  aneurysm  is  given  with  the  description  of  the 
disease.  Prom  new  gro\vths  the  distinction  lies  in  the  fact  that  there 
the  heart  sounds  are  unchanged  in  character  and  are  heard  only  over 
their  noimial  areas,  and  are  not  co-extensive  ivith  the  increased  area, 
which  would  be  the  case  were  the  heart  itself  enlarged;  and  that  the 
inspection  signs  of  enlarged  heart  are  absent.  Cancer  gives  cachexia. 
The  history,  the  dyspnoea  and  the  subjective  signs  all  aid  in  the  sepa- 
ration of  the  conditions.  Consolidation  of  lung  tissue  overlapping  or 
adjacent  to  the  heart  may  mislead.  Auscu^ltation  will  generally  set- 
tle the  difficulty. 

Displacements  of  the  Area  of  Didlness  occasionally  result  from 
tumors.  Emphysema  causes  a  slight  displacement  as  well  as  decrease 
of  area.  Effusions  are  the  most  potent  causes  of  displacement,  espe- 
ciallv   when  thej'   are   into   the  left   sac.      (For   diagnosis   see   Pleu- 


170  THE    HKART 

ritis.)  Ail'  in  llic  pleural  sac  upcialcs  iii  a  like  iiiaiiiici'.  (Sit  I'licii- 
mothorax.)  Disphu'eiuoiits  due  tti  iiitVa-diapliraL^nial  ic  causes  arc  list- 
ed under  palpation  in  the  preeedinti'  section. 

Arscri/PATiox  of  TIIK  IIKAKT. 

When  the  ear  or  a  stethoscope  is  applied  over  an\-  pail  nf  the 
£hest  of  a  healthy  individual  the  heart  sounds  are  heard  with  vary- 
ing distinctness.  If  these  .sounds  are  analyzed  they  are  found  to  con- 
sist of  two  distinct  and  easily  recognized  coni])onents,  separated  from 
each  other  by  an  interval  of  silence.  While  each  of  these  sounds  va- 
ries in  intensity,  as  we  change  the  position  of  the  stethoscope,  yet  each 
is  audible  over  the  entire  cardiac  area,  and  preserves  its  distinctive 
quality  throughout.  It  is  difficult  to  graphically  represent  these 
sounds,  and  no  better  way  has  yet  been  suggested  than  the  tinie- 
Tionored  one  of  imitating  them  by  pronouncing  the  two  monosy!]al)les. 
"lub"  and  "dup."  They  represent  respectively  the  lirst  and  the  sec- 
ond sounds  of  the  heart. 

The  first  .sound,  lub,  is  best  heard  at  the  apex,  where  its  inten- 
sity is  greatest,  and  where  it  is  not  only  louder  than  the  second,  or 
dup.  sound,  but  is  of  longer  duration  than  that  sound  as  well  as  more 
booming  or  resonant  in  character  and  lower  in  pitch.  The  second 
sound  is  best  heard  immediately  over  the  sternum,  opposite  the  sec- 
ond interspace.  It  follows  from  what  has  been  said  that  this  sound 
is  higher  in  pitch,  shorter  in  duration,  having  less  of  a  boom  and  moi-e 
of  a  sharp,  cut-otf  character  at  its  termination  than  the  first.  And 
although  the  first  sound  li.stened  to  at  tliis  point  is  less  prolonged  and 
less  weighty  than  it  is  at  the  apex,  yet  at  whatevei-  part  of  the  chest 
they  may  be  heard  the  healthy  second  soiuid  is  shorter  in  duration 
and  higher  in  pitch  than  is  the  first. 

The  two  sounds  present  further  modifications  when  listened  to 
over  the  right  ventricle  and  over  the  pulmonary  artei'y,  but  in  the 
main  they  preesrve  the  characters  already  attributed  to  them.  The 
character  and  modifications  of  the  sounds  are  best  learned  by  expe- 
rience, since  a  wordy  attempt  to  describe  minute  diii'erenees  is  con- 
fusing rather  than  helpful.  When  we  examine  into  the  mechanisni 
of  the  sounds  we  can  still  better  appreciate  their  character. 

The  principal  element  in  the  production  of  the  first  sound  is  the 
closure  of  the  aurieulo-ventricular  valves,  but  along  with  this  sound 
and  modifying  its  ipiality  must  be  named  the  apex  impact,  the  note  of 


THE  TRICU5PID  VALVE' 

THE  MITRAL  VALVE 


APEX 

THE  PULMONARY  VALVE 
THE  AORTIC  VALVE 


PLATE  MIL 


THE    HEART  171 

:niuscle  contraction,  and  the  noise  made  by  the  rush  of  blood  through 
the  aorta  and  the  puLmonarj^  arteries.  Were  it  not  for  these  modify- 
ers,  neither  its  quality  nor  its  duration  would  diii'er  from  that  of  the 
second  sound,  which  is  produced  solely  by  the  closure  of  the  aortic  and 
pulmonary  semilunar  valves,  caused  by  the  reflux  of  the  blood  column 
upon  their  leaflets ;  hence  almost  the  sole  variation  to  which  the  second 
.sound  is  subject  in  health  is  diminution  of  its  intensity  as  we  recede 
from  the  point  where  it  is  produced.  As  has  been  stated,  the  two 
sounds  are  separated  by  a  pause,  and  a  second  interval  follows  the 
■  completion  of  the  heart  beat,  this  second  pause  being  approximately 
tkree  times  as  Ions'  as  the  first. 


3-5     £ 


Mm  m  1 1  mu  m  1 1  m  n  m~ 


R    .     8.C  .    D. 


6      C, 


T^g-  39 — Auscultation  of  normal  heart  sounds.  Relative  length  of  normal  heart 
sounds  drawn  to  a  scale  of  i-io.  Each  division  below  the  line  represents 
i-io   second. 

While  the  normal  heart  rate  for  adults  is  upwards  of  seventy 
per  minute,  yet  for  convenience  we  may  assume  a  rate  of  sixty  beats 
per  minute,  since  this  rate  greatly  facilitates  the  description.  Then  one 
beat  or  complete  heart  cycle  will  occupy  one  second.  If  now  we 
divide  the  complete  cycle  occupying  one  second  into  tenths  of  a  second, 
the  relative  length  of  the  factors  which  make  up  the  cycle  will  be, 
first  sound,  4-lOths,  short  pause,  1-10,  second  sound,  2-lOths,  long 
pause,  3-lOths;  total.  10-lOths.  This  is  indicated  by  the  accompanying 
.simple  diagram . 

A — Ventricular  systole. 

B — Short  pa^ise. 

C — Closure  of  aortic  and  pulmonary  valves. 

D — Ventricular  diastole. 


172  Till-:    IIKAHT 

As  said,  tlic  Imii;'  pause  or  jjuriod  ol'  I'cst  vai'ics  with  llic  heart's 
rate.  When  the  heart's  pulsations  toliow  carh  nthfi'  with  iircat  i-a])id- 
ily,  tlie  period  of  rest  is  i-edueed  tn  thr  iiiiniiinnn.  and  when  the 
heart's  action  is  slow  the  prridd  n\'  rest  is  Icimthcnrd  and  ln-comes 
longer  than  the  period  of  action.  On  I  In'  ntiicr  hand,  whm  licating 
rapidly  the  long  pause  so  lessens  as  to  \ir  shurtn'  than  thr  prrind  of 
action,  hence  the  normal  sounds  of  I  lie  hrait  nia>-  si'iMninelv  ehauti'c 
their  relationship  to  one  another,  and.  when  the  action  liecomes  very 
rapid,  to  the  listener  the  first  sountl  sccnis  to  fnlhiii'  the  sicond  sound, 
since   the    interval    hctwen    the   saaud  sound    and    tin-    recurrent    firxl 

■  mmm 

\.TV     l;;l|il.l     II, Mil, 

■llllllll 

M<pilciiit<'lv    Kiii.hl. 

■illlllll 

■I       11       III  I       ■ 

Fig.   40 — Diagram   illustrating  the  relationship   in   time  of  the   lirst   and    secoiul 
heart    sounds    in    different    rliytlnns. 

soiuid  is  now  longer  than  the  interval  hetween  the  first  sinind  and 
the  second;  a  state  of  affairs  which  may  he  embarrassine'  to  the 
student. 

In  the  slowly-acting  heart  the  distinction  is  easy,  since  it  is  only 
nece.ssary  to  remember  that  the  long  silence  follows  the  second  souud, 
bitt  in  eases  of  rapid,  irregnlar  action  accompanied  by  a  change  in 
the  qualities  of  the  two  sounds  which  makes  them  resemble  each  other, 
or  when  onli^  the  first  sound  is  audible  at  the  base  and  the  secoiul  only 
audible  at  the  apex,  the  difficulty  of  separation  is  considerable. 

The  accompanying  diagram  may  aid  in  comprehendine  the  rela- 
tionship. 


PLATE  IX. 


The  cardinal  points  of  tlie  valve  areas.     Points  at  wliich  valve 
sounds  are  best  isolated. 


THE    flEAET  173 

POSITION  OF  THE  VALVES  OP  THE  HEART. 

The  valves  are  all  located  within  such  a  narrow  radius  that  a 
silver  quarter  may  be  so  placed  as  to  cover  a  portion  of  each.  Indeed, 
the  aortic  and  the  pulmonary  semi-lunar  valves  are  separated  from 
each  other  only  by  the  thickness  of  the  aortic  wall.  The  two  auriculo- 
ventricular  valves  and  the  aortic  valve  are  in  one  plane,  which  forms 
a  diagonal  of  the  thorax.  As  described  in  the  various  text-books, 
much  variation  in  the  location  of  these  valves  will  be  foiind  to  exist. 
Most  recent  anatomical  research  as  to  their  exact  topographical  posi- 
tion locates  them  as  follows:  The  pulmonary  valve  lies  beneath  the 
third  left  costal  cartilage,  but  close  to  its  junction  with  the  sternum, 
and  is  the  inost  superficial  as  well  as  the  highest  up  of  all  the  valves. 

Were  the  position  of  the  heart  vertical  the  aortic  valve  would  lie 
almost  exactly  behind  the  pulmonary  valve,  but,  viewed  from  in 
front,  the  heart  is  the  subject  of  a  double  tilt.  The  vertical  axis 
points  from  right  to  left  and  the  antero-posterior  axis  points  from 
above  downward.  For  this  reason  the  aortic  valve  occupies  a  lower 
level  than  the  pulmonary  valve,  at  the  same  time  being  deeper- 
seated,  lying  behind  the  left  edge  of  the  sternum,  opposite  the  upper 
part  of  the  third  interspace. 

The  mitral  valve,  the  most  deeply  placed  of  the  four,  lies  beneath 
the  left  half  of  the  sternum,  opposite  its  junction  with  the  fourth 
cartilage.  The  right  auriculo-ventricular,  or  tricuspid  valve,  is  more 
superficial  than  either  the  mitral  or  the  aortic  valves ;  its  aperture  is 
almost  vertical,  and  it  lies  under  the  middle  of  the  sternum,  opposite 
the  fourth  interspace.  The  upper,  inner  segment  of  its  opening  over- 
laps the  lower  inner  segment  of  the  mitral  orifice.  It  will  be  seen, 
therefore,  that  all  of  the  valves  lie  vmder  the  middle  and  left  half  of 
the  sternum,  between  the  upper  border  of  the  third  cartilage  and  a 
short  distance  below  the  fourth. 

ISOLATION  OF  THE  VALVE  SOUNDS. 

It  might  strike  the  student  as  a  difficult,  if  not  an  insurmount- 
able, task  to  isolate  the  sounds  arising  from  four  structures  so  nearly 
superimposed.  Such,  indeed,  would  be  the  case  were  it  not  that  the 
points  of  isolation,  the  point  at  which  each  separate  sound  is  best 
heard,  does  not  correspond  to- the  surface  area  above  given,  nor  even 
to  the  superficial  point  nearest  to  the  actual  seat  of  the  valve.  This  is 
due  to  the  fact  that  the  sounds  emanating  from  the  valves,  made  bv 


17-4  THE     1  IK  ART 

the  iiiipiiigiiig  ni'  the  blood  cunriit  ay:ainst  lln'ir  Icatlcls  aud  from 
theii'  closure,  is  best  propagated  in  tlie  direction  of  I  he  hlood  current; 
hence  the  apparent  discrepancy.  The  locality  in  wliich  the  mitral 
sound  is  best  heard  is  over  the  apex  area.  The  tricuspid  is  best  heard 
close  to  the  left  border  of  the  sternum,  at  the  fifth  interspace,  or  over 
the  xiphoid  cartilage.  The  aortic  valve  sound  is  loudest  and  clear- 
est, aud  should  therefore  be  listened  to,  on  the  right  of  the  sternum  in 
the  second  interspace,  where  the  aorta  approaches  closest  to  the  chest 
wall,  for  which  reason  the  second  right  costal  cartilage  is  named  the 
aortic  cartilage.  On  the  opposite  side  of  the  sternum  (left),  in  the 
same  interspace,  is  best  heard  the  pulmonary  valve.  This  gives  us 
four  cardinal  points  at  which  the  four  sounds  are  best  isolated,  at 
which  their  individual  r|ualitii\';  are  strongest  and  easiest  to  dilTer- 
entiate. 

IXFLUExNCES   WHICPl    CAUSE    ALTEKATIO.XS    IX    XOH.MAL 
SOUNDS. 

Since  inflation  of  the  lungs  increases  the  thickness  of  the  heart 
cover,  diminishes  its  exposed  area,' as  well  as  causes  recession  of  the 
organ,  all  the  sounds  are  better  heard  during  forced  exi)iration.  Ad- 
vantage should  therefore  be  taken  of  expiration  to  differentiate  sounds 
which  are  otherwise  inaudible  .or  only  feebly  heard.  The  normal 
sounds  of  the  heart  are  best  heard  with  the  patient  sitting  or  stand- 
ing, although  its  areas  are  best  mapped  out  with  the  patient  lying 
on  his  back.  But  in  case  of  suspected  disease  of  the  organ  it  is  abso- 
lutely essential  to  percuss  and  to  auscultate  the  patient  both  while 
stanclinfj  and  while  lying  down.  The  diagno.sis  may  be  materially  in- 
fluenced by  this  precaution,  and  doubtful  cases  may  be  removed  to 
the  realm  of  certainty  by  the  procedure.  Thus,  a  murmur  may  en- 
tirely disappear  when  the  patient  lies  down,  and  reappear  when  he 
rises.  It  may  confidently  be  stated  that  such  a  murmur  is  not  organic. 
On  the  other  hand,  a  murmur  which  is  only  audible  when  the  patient 
is  in  the  recumbent  posture  is  probably  organic. 

CONDITIONS   WITTCTI    AFFECT    THE    INTENSITY   OF    THE 
SOUNDS. 

The  normal  heart  sounds  are  heard  with  greater  intensity,  as  well 
as  over  a  larger  area,  in  persons  whose  chest  walls  are  thin  :  also  as  the 
result  of  excitement:  in  cardiac  liy])ertrophy :  dni-ing  the  sthenic  stage 


THE    HEART  175 

of  fevers ;  as  the  result  of  certain  cardiac  stimulants ;  and  as  the  result 
of  increased  density  of  adjacent  pulmonary  tissue.  As  a  resiilt  of  the 
last-named,  they  may  be  conducted  to  very  distant  points.  The  full 
significance  of  this  sign  is  considered  under  the  section  on  Phthisis. 

Conversely,  the  heart  sounds  are  rendered  weaker  even  in  health 
by  abnormal  causes.  Fear  or  fright  so  acts,  as  do  debility,  wasting 
diseases,  and  the  anajmias.  i\Iany  drugs  have  the  power  to  depress, 
the  heart,  and  careful  inquiry  should  be  made  as  to  whether  the 
patient  is  addicted  to  drug  habits.  Diseases  such  as  fatly  degeneration 
of  the  muscles ;  mechanical  causes  interfering  with  cardiac  action, — as 
effusion  into  the  sac  of  either  the  lung  or  the  heart, — produce  like 
results.  Not  infrequently  one  encounters  a  heart  whose  sounds  arc 
abnormally  weak  and  inaudible  without  any  assignable  cause,  the 
subjects  being  generally  women. 

Except  in  cases  of  cardiac  hypertrophy,  or  when  consolidation  of 
tissue  has  taken  place,  the  extent  of  the  area  over  which  the  sounds- 
are  audible  has  no  special  significance.  Full  inspiration  obscures 
certain  of  the  sounds.  This  is  particularly  true  of  the  pulmonary 
valve  sound  heard  on  the  left  side  in  the  second  interspace.  Likewise- 
during  full  inspiration  the  aortic  sound  is  lightened  in  intensity.  The 
apex  sound  is  now  best  heard  nearer  the  median  line,  as  the  apex  is 
moved  in  that  direction  by  the  lung  expansion.  Nervous  excitement 
and  exercise  temporarily  increase  the  intensity  of  both  the  heart's 
action  and  its  sounds.  Siich  action  is  named  palpitation.  Advantage- 
may  be  taken  of  exercise  to  temporarily  intensify  the  sounds  when 
auscultating  a  heart  whose  action  is  feeble.  Softening  of  the  walls 
diminishes  the  intensity  of  both  the  sounds,  particularly  the  first.  This 
is  observed  in  many  acute  febrile  and  infectious  diseases,  and  in  the 
degenerations.  Thickening  of  the  walls  changes  the  i|uality  of  the 
tone,  especially  of  the  first  sound,  lengthening  it  and  rendering  it 
more  heavy  and  booming,  thus  lowering  the  pitch  of  its  note.  This  is 
the  resiilt  of  hypertrophy,  however  brought  about. 

The  quality  of  the  second  sound  is  more  constant,  and  changes, 
materially  only  in  disease  of  the  valves  or  in  grave  alterations  in  the 
composition  of  the  blood.  Increased  back  pressure  on  the  valves 
causes  a  forcible,  snap-like  closure,  which  augments  the  second  sound 
both  in  clearness  and  intensity.  This  is  especially  the  case  with  the 
pulmonary  second  sound,  and  in  lung  consolidation  is  an  important 


17(j  TiiK    iii;aut 

siyn  of  beyiuning-  of  pulinoiiary  inlillration.  Aiicurysiii  of  llu'  aorla 
will  cause  accentuation  of  the  second  sound  of  that  valve. 

In  ease  of  fluid  in  the  perieai'dial  sac  both  sounds  sccni  to  conic 
from  a  distance  and  to  have  a  feeble,  inufllcd  charadiM'.  Otlici-  rliaiigcs 
worthy  of  notice  are  the  reduplicalimi  oT  due  iw  llic  tit  her  snuiid  and 
the  lengthening  or  shortening  of  eillicr  iiitrr\al.  Ihc  lonu  m-  \]u-  short, 
between  the  sounds. 

Kcduplicatioii.  (ii'nci'all\'  it  is  Ihc  sccmid  sdiiiid  which  is  I'c- 
peated.  This  curious  ijIicuoimcuom  can  be  explained  only  im  I  lie 
hypothesis  that  the  corresponding  valves,  the  aortic  and  the  pul- 
monary on  the  one  hand,  and  the  mitral  and  the  tricuspid  mi  llu' 
other,  fail  to  close  synchronously;  or  else  on  the  assumption  thai  the 
two  allied  chambers  of  the  heart  fail  to  contract  in  unison.  Such  a 
theory  as  the  first  is  very  plausible  and  could  be  brought  alioul  h,\-  any 
relatively  impoi-tant  change  in  the  blood  pressure  of  the  two  circula- 
tions, the  pulmonary  and  the  systemic.  Prom  the  nat\iic  of  the  ease, 
the  former  more  often  will  be  at  fault,  and  pulmonary  eugoi'geinent  by 
increasing  the  back  pressure  on  the  doors  of  the  pulmonary  artery  will 
cause  that  valve  to  anticipate  slightly  its  time  of  closure,  and,  indeed, 
such  reduplication  often  occurs  after  running,  as  is  seen  in  sprinters. 
In  the  same  way  narrowing  of  the  blood  channels,  the  effect  of  sclerosis 
of  large  organs,  particularly  the  liver  or  the  kidneys,  would  produce 
similar  results  on  the  aortic  valve. 

Retardation  in  the  closure  of  the  trieu.spid  valve  eau.ses  redupli- 
cation of  the  first  sound. 

Reduplications  are  sometimes  intermittent,  sometimes  rhythmical, 
that  is,  they  skip  a  certain  number  of  beats,  recur  at  stated  intervals, 
skip  and  recur  almost  melodiously. 

Shortening  of  the  silent  intervals  in  relation  to  pulse  rapidity  has 
.already  been  referred  to. 

ADVENTITIOUS  SOUNDS. 

The  normal  sounds  of  the  heart  may  be  replaced  by  or  he  inter- 
mingled with  other  sounds  adventitious  in  their  nature,  totally  dift'er- 
■ent  in  cpxality  from  the  normal  sounds.  The  recognition  of  these 
sounds  and  the  correct  interpretation  of  their  relation  to  the  heart's 
mechanism,  are  of  prime  importance  in  the  diagnosis  of  the  many 
^ailments  to  which  the  structure  is  liable.  These  new  sounds  are  classi- 
fied as    pfricardial  or  endocardial. 


LEFT  Vf.NTR(CLt 


PLATE  X. 
THE  TRICUSPID  AND   PULMONARY  VALVES. 


From  Cunningham's  Anatomy 
by  permission  of  Wm.  Wood  &  Co. 


THE    HEART  177 

Those  sounds  which  are  due  to  alterations  in  the  structure  or 
changes  in  the  condition  of  the  adjacent  layers  of  the  pericardial  sac, 
namely,  the  visceral  and  the  parietal  layers,  are  termed  exocardial 
or  pericardial  murmurs.  Such  changes  are  usually  the  result  of  in- 
flammation, but  may  be  caused  by  external  pressure.  From  their 
character  they  are  called  friction  sounds.  The  manner  of  their  pro- 
duction will  be  considered  hereafter. 

Those  sounds  that  originate  from  changes  occurring  within  the 
organ,  which  are  essentially  changes  affecting  those  reduplications  of 
its  serous  lining  which  form  the  valves,  are  classified  as  endocardial. 
In  contradistinction  to  the  friction  sounds  they  are  termed  murmurs. 

Endocardial  murmurs  vary  extremely  in  character,  pitch,  tone, 
duration,  location,  time,  and  in  the  distance  and  direction  in  which 
they  are  transmitted.  They  often  receive  their  names  from  a  fancied 
resemblance  to  some  sound  in  nature;  hence,  we  read  of  blowing, 
cooing,  rustling,  clacking,  rasping,  grating  or  filing  murmurs.  Such 
terms  are  useful  since  they  generally  roughly  indicate  the  pitch.  The 
majority  of  murmurs  are  soft  and  blowing,  yet  occasionally  they  are 
so  harsh  and  noisy  a.s  to  be  audible  to  the  bystanders. 

CAUSES  WHICH  PRODUCE  MURMURS. 

As  to  the  exact  physical  or  mechanical  causes  which  operate  to 
produce  the  above-described  sounds  we  have  no  positive  knowledge, 
but  a  plausible  theory  may  be  formed  by  reasoning  from  existing 
pathologic  conditions.  We  know  that  murmurs  accompany  grave 
changes  in  the  composition  of  the  blood  without  any  recognizable 
structural  alterations  of  the  heart,  the  valves,  or  the  vessels.  Such 
murmurs  are  called  hcemic  murmiirs,  and  are  described  as  functional 
or  accidental.  They  are  associated  with  most  of  the  grave  anasmias, 
but  occur  in  other  diseases  as  well.  By  some  writers  the  term  inor- 
ganic murmurs  is  applied  to  sounds  so  arising ;  both  this  term  and  the 
name  nonorganic  are  objectionable  in  this  sense. 

On  the  other  hand,  murmurs  are  associated  with  certain  path- 
ologic alterations  of  structure  which  can  stand  only  in  a  causative 
relation  thereto.    Enumerated  they  are : 

(a.)   Narrowing  of  the  orifices  through  which  the  blood  finds  exit. 

(b.)   Widening  of  the  orifices. 

(c.)   Narrowing  or  widening  of  the  bloodvessels  or  heart  chambers. 

(Changes  under  a.  and  b.  are  in  effect  changes  in  the  valves,  such 


ITS  THE    HEART 

as  roiitrlieuiug,  thickening,  or  puckering  of  the  leaflets, — ileformities 
resulting  from  sclerosis.  Inflammatory  deposits  or  vegetations  result 
in  perforations  or  contractions  of  the  leaflets.) 

(d.)  Imperfect  opening  or  closure  of  the  valves  due  to  causes 
mentioned  and  to  shortening  of  the  chorda  tendinra. 

It  were  profitless  to  di.scuss  the  laws  of  hydraulics  and  hydro- 
statics which  might  seem  to  apply.  Suffice  it  to  say  that  the  noises 
are  produced  by  the  vibrations  set  up  in  both  liquids  and  solids  by 
the  circulation  of  the  blood  over  the  altered  structures.  It  is  also 
conceivable  that  blood  alterations  may  influence  these  murmurs, 
especially  by  increasing  or  diminishing  their  intensity. 

Organic  murmurs  may  be  produced  at  any  of  the  four  valves  of 
the  heart,  but  by  far  the  most  common  valve  to  be  affected  is  the 
mitral:  next  in  order  of  frequency  is  the  aortic,  then  the  tricuspid, 
with  the  pulmonary  a  bad  fourth.  The  aortic  and  mitral  valves 
together  are  affected  four-tifths  as  often  as  the  aortic  valve  alone. 

RESULTS  OF  VALVl'LAR  I.MPAIRME.XT. 

Inability  of  a  valve  to  close  so  as  to  render  itself  "water-tight"'  is 
called  insufficiency,  and  the  return  flow  of  blood  through  the  orifice  is 
called  regurgitation.  The  causes  have  been  enumerated.  It  is,  how- 
ever, well  established  that  the  phenomenon  of  regurgitation  may 
occur  during  excited  and  violent-acting  states  of  the  heart,  when  both 
valve  and  muscle  are  perfectly  healthy.  Such  inefficiency  can  be 
explained  only  as  a  temporary  expansion  of  the  valvular  ring  or  by 
imperfect  closure,  just  as  other  automatic  acts  are  disturbed  by  over- 
stimulation. So,  also,  altered  states  of  the  blood  may  be  accompanied 
by  all  the  audible  signs  of  regurgitation  without  organic  change  being 
present.  Xo  doubt  in  many  of  these  eases  the  insufficiency  is  actually 
present,  only  to  pass  away  with  the  improvement  in  the  general 
condition. 

Contraction,  puckering  or  thickening  of  the  valve  leaflets,  or 
deposits  upon  their  surface,  shortening  and  thickening  of  the  chordce 
tendinccE.  and  deposits  into  the  valvular  fibrous  ring,  operate  to  pro- 
duce such  a  narrowing  of  the  valve  opening  as  to  interfere  with  the 
outflow  of  the  blood.  Such  interference  is  called  valvular  stenosis. 
The  aortic  and  the  left  aurieulo- ventricular  orifices  are  oftenest. 
affected. 


THE    HEART 


17a 


TIME  OF  CARDIAC  MUM'IURS. 

Having  considered  the  physiologic  action  of  the  heart  and  the 
Ttnechanism  of  the  murmurs  we  are  prepared  to  discuss  the  relation- 
ship of  the  latter  to  the  former  in  point  of  time;  in  other  words,  to 
fix  the  rhythm  of  the  murmur  as  regards  those  acts  which  constitute 
the  complete  heart  cycle,  viz.,  the  systole,  the  diastole  and  the  period 
of  rest. 

A  murmur  which  accompanies  only  a  single  act  of  the  heart,  the 
filling  or  emptying  of  a  chamber,  the  opening  or  closure  of  a  valve. 


R 


R 


R 


R 


A     PRESYSTOLIC     MURMUR 


A    SYSTOLIC    WURMUH. 


pui 


A     DIASTOLIC     (MURMUR. 

Fig.   41 — Diagram  illustrating  the   single  or  simple  murmurs. 

is  classified  as  a  simple  or  single  murmur.  -Murmurs  which  arise  in 
connection  with  two  of  these  acts,  constituting  a  union  of  the  simple 
murmurs,  are  called  compound  murmurs.  Compound  murmurs  aris- 
ing at  one  orifice  or  valve  are  called  double  mvirmurs,  when  originating 
at  different  orifices  they  are  called  combined  or  associated  murmurs. 

Every  simple  valvular  miirmur  has  one  of  three  relations  to  the 
sounds  of  the  heart,  one  of  three  places  in  the  cardiac  cycle. 

First,  the  murmur  may  be  synchronous  with  the  contraction  of 
the  auricles,  in  which  ease  it  is  auriculo-systolic.  In  time  such  a 
murmur  precedes  the  first  sound,  running  up  to  that  sound  but  ending 


li^O  TlIK    HEART 

at  the  inoinent  of  its  proclueliuii.  The  relation  which  auy  murumr 
l)ears  to  svstole  or  diastole  may  best  be  ascertained  by  placing  the 
stethoscope  over  the  seat  of  the  mnrnuir,  and,  while  the  tip  of  the 
finger  records  each  systole,  the  attentive  ear  consigns  the  luuiinur  to 
its  proper  period  in  the  heart  cycle. 

Second,  the  nuirmin-  may  be  synchronous  with  tln'  contract  ion 
of  the  vcntrwles,  in  which  case  it  is  centricitlar-aystolic.  In  point  of 
time  snch  a  murmur  follows  the  first  sound  of  the  heart  and  ends 
.somewhere  between  the  first  and  the  second  sound.  Honietimes  the 
murmur  is  so  prolonged  as  to  almost  touch  the  second  sound.  It  is 
<iuite  apparent  that  in  this  case  the  nnirnnir  may  actually  begin  with 
the  beginning  of  systole,  bnt  will  not  be  apparent  until  the  cessation 
of  the  true  systolic  sound,  hence  will  follow  immediately  upon  that 
sound  as  though  it  were  a  prolongation  of  systole. 

Third,  the  murmur  may  be  synchronous  with  the  dilatation  of  the 
ventricles,  in  which  case  it  is  ventricular-diastolic.  In  point  of  time 
such  a  murmur  follows  the  second  sounel  and  ends  during  the  interval 
hetwen  the  second  sound  and  the  recurrence  of  the  first  soTuid. 

Briefiy  recapitulatetl  the  simple  ninrmurs  are,  therefore,  presys- 
tolic, systolic,  or  diastolic  in  relation  to  the  functions  of  the  heart. 

In  accordance  with  the  simple  scheme  adopted  for  representation 
■of  the  heart  sounds  we  may,  by  a  slight  modification,  represent  also 
the  simple  endocardial  murmurs  antl  their  relations  to  the  normal 
sounds : 

Various  combinations  of  the  simple  murmurs,  constituting  the 
■compound  or  double  nnirmurs,  are  not  of  rare  occurrence,  and  greatly 
increase  the  perplexity  of  eori'ectiy  timing  them.  They  are  illustrated 
in  Diagram. 

The  most  common  of  these  associated  or  combined  conditions,  as 
-\ve  shall  s.>e.  is  the  co-existence  of  a  ventricular-systolic  and  a  ven- 
tricular-diastolic  murmur;  then,  of  an  auricular-systolic  with  a  ven- 
tricular systolic  murmur.  In  certain  cases  of  long  standing,  in  which 
two  or  more  valves  are  affected,  four  or  even  six  murmurs  might 
possibly  be  present  in  the  same  heart. 

LOCATION   OF   CARDIAC  MURMURS.     VALVULAR   AREAS. 

The  point  of  origin  of  a  murmur,  the  direction  and  the  limit  of 
its  diffusion,  are  pretty  constant  quantities,  and  clinical  experience 
combined  with  po.st-mortem  confirmation  have  established  certain  fields 


THE    HEART 


181 


which  are  called  the  areas  of  the  murmurs.  The  location  or  seat  of 
the  murmiu"  is  determined  by  finding  its  point  of  greatest  intensity; 
by  mapping  out  the  field  over  which  the  sound  is  audible,  the  direction 
and  extent  of  its  transmission,  in  conjunction  with  the  associated 
symptoms.  Even  when  all  these  elements  are  weighed  there  is  a 
possibility  of  error,  and  experience  rather  than  precept  must  teach 
the  student  that  the  presence  of  an  adventitious  sound  does  not  neces- 
sarily mean  organic  disease,  nor  does  its  absence  indicate  freedom 
from  such  a  malady. 

We  examine  successively  the  four  cardinal  points  already  named, 
at  which  normallv  the  four  valve-souuds  attain  their  maximum  in- 


K 


R 


J^ 


AS  -t  vs 


AS  +Vi 


AS  +VS-J-V  0 


fl 


R 


>/6 


vo 


vs^  +  vp 


Fig.  42 — The  combined  murmurs.     AS  Auricular  systole.     VS  Ventricular  sys- 
tole.    VD  Ventricular  diastole. 

tensity  (see  plate).  If  a  murmur  is  clearest  and  most  distinctly  heard 
at  the  apex,  it  is  strong  presumptive  evidence  that  it  concerns  the 
mitral  valve  and  the  left  ventricle.  The  mitral  area  is  a  small  circle 
surrounding  the  apex  of  the  left  ventricle,  as  illustrated  in  the  accom- 
panying plate.  Its  location,  therefore,  changes  with  changes  in  the 
position  of  the  apex,  and  enlarges  with  enlargement  of  the  ventricle ; 
hence  the  necessity  of  accurately  locating  the  apical  point.  Mitral 
murmurs  are  more  generally  propagated  to  the  left  than  to  the  right 
of  the  apex.  Especially  is  this  true  of  regurgitant  murmurs.  The 
obstructive  mitral  murmur  is  apt  to  keep  within  bounds,  and  its  point 
of  greatest  intensity  corresponds  pretty  accurately  with  the  center 
of  our  circle — that  is,  it  is  a  little  to  the  right  of  the  apex  point. 


182  I'lii:    iiivMiT 

A  correspoinliui;  i-irdc  on  the  hack,  ol'  wliicli  llic  iiifi'rior  aiiiili' 
of  the  left  sca])iiln  is  tlu'  cciitiT,  will  often  enclose  a  field  in  which  are 
distinctly  heard  the  mitral  niiirnmrs,  especially  in  emaciated  persons, 
and  this  field  shoidd  not  be  overlooked.  This  is  admirably  shown  in 
the  photograph  of  the  patient  with  mitral  insufficiency,  on  pape  209, 
in  which  ease  the  muriiiiii'  was  transmitted  directly  to  the  area  shown. 
without  following  around  the  axillary  space. 

Both  DaCosta  and  Naunyn  draw  attentinn  id  llir  \'nv\  that  some 
mitral  murmurs  have  their  seat  of  greatest  intensity,  not  in  the  above 
area,  but  in  the  second  or  third  interspace,  an  ineh-and-a-half  or  two 
inches  outside  the  left  border  of  the  sternum. — that  is,  ,inst  beyond 
the  pulmonai-y  area,  for  lesions  of  which  v;ilvc  lliey  might  possibly  be 
mistaken.  The  murmurs  thus  centering  ai'e  usually  regurgitant,  and 
the  explanation  lies  in  the  fact  that  at  the  point  indicated  the  auricle 
is  most  superficial,  and  that  it  crops  out  still  further  when  dilated  by 
the  regurgitated  fluid.  Some  of  the  murmurs  assigned  incorrectly  to 
the  pulmonary  valve,  are,  according  to  Balfour,  in  r(>ality  mitral  mur- 
murs so  caused.  While  the  center  of  intensity  is  highc  r  up  in  these 
cases  than  the  usual  mitral  center,  yet  this  should  not  deceive  the 
cautious  observer.  Their  area  is  outside  the  pulmonai'y  area,  and  they 
are  heard,  but  with  less  distinctness,  in  the  mitral  circle. 

Tricuspid  Area.  If  the  mnrnnir  is  best  heard  over  oi-  at  llie  left 
margin  of  the  ensiform  cartilage  where  the  right  ventricle  is  exposed, 
it  is  highly  probable  that  it  emanates  therefrom,  and  that  the  tricuspid 
valve  is  the  malefactor.  In  ease  of  considerable  dilatation  or  hypei-- 
trophy  of  the  right  ventricle  the  valve  moves  towards  the  left,  and  the 
sound  is  heard  along  the  sixth  intei'space,  (sixth  and  seventh  i-ibs) 
to  the  left  of  the  sternum. 

The  tricuspid  area  is  triangular  in  shape,  larger  in  its  bounds 
than  the  preceding  area,  since  it  lies  more  to  the  front.  Its  limitations 
are  a  line  cro.ssing  the  sternum  from  the  lower  border  of  the  fifth 
right  costal  cartilage  to  the  upper  border  of  the  third  left  cartilage, 
thence  downward  to  the  center  of  the  mitral  area  above  described, 
thence  aci-o.ss  the  ensiform  cartilage  to  the  point  of  beginning.  The 
diagram  gives  a  clearer  idea  of  the  area  than  can  be  given  by  descrip- 
tion. The  left  boundary  coincides  with  the  left  interventricular 
cardiac  groove. 

Pulmonari/  Area.  If  a  lesion  of  the  pulmonary  valve  exists  the 
auditoi'y  area  is  limited  to  a  small  circle  over  the  origin  of  that  arterv 


THE    HEART  183 

in  the  second  and  upper  third  left  interspaces.  The  inner  border  of 
the  circle  touches  the  left  edge  of  the  sternum.  These  murmurs  are 
superficial,  hence  distinct.  The  sound  disappears  when  searched  for 
across  the  right  sternal  border,  but  may  be  indistinctly  transmitted 
upward  toward  the  left  sterno-clavicular  articulation.  It  is  not  con- 
ducted into  the  great  vessels  of  the  neck,  nor  is  it  audible  in  the  apex 
area.  These  limitations  serve  to  separate  it  from  both  mitral  and 
aortic  murmurs.  Organic  pulmonary  munnurs  never  arise  in  inter- 
current diseases,  although  functional  murmurs  are  often  credited  to 
this  role.' 

Aortic  Area.  If  the  region  in  which  centers  the  intensity  of  the 
adventitious  sound  be  the  upper  sternal,  especially  if  the  region  lie 
to  the  right  of  the  bone,  the  murmur  in  all  probability  arises  from 
a  defective  aortic  valve.  These  murmurs  are  heard  with  little  varia- 
tion of  their  intensity  beneath  the  manubrium,  and  on  both  sides  of  the 
sternum,  in  the  third  left  and  in  the  second  right  interspaces,  which 
latter  is  .just  below  the  aortic  cai'tilage,  at  which  point  aortic  murmurs 
attain  their  maximum  intensity,  as  a  rule;  bvit  owing  to  the  position 
of  the  aorta  and  .the  direction  of  its  current  they  are  audible,  ofttimes, 
the  entire  length  of  the  breast-bone,  and  in  cases  of  regurgitation  the 
center  of  intensity  is  not  infrequently  over  the  ensiform  cartilage, 
and  even  extends  over  to  the  mitral  area. 

Aortic  obstructive  murmurs  are  transmitted  into  the  vessels  of 
the  neck  with  considerable  clearness  and  intensity,  which  fact  distin- 
guishes them  easily  from  all  other  murmurs.  Even  regurgitant  aortic 
murmurs  may  be  heard  faintly  in  the  cervical  vessels.  The  obstructive 
miirmur  is  sometimes  heard  in  the  course  of  the  great  vessels  down 
the  spine  and  even  in  the  extremities.  The  diagram  shows  the  area 
of  these  murmurs  as  it  appears  on  the  anterior  aspect  of  the  chest. 

illTRAL  MURMURS. 

When  during  the  long  cardiac  pause  the  blood  returns  from  the 
lungs  to  the  left  aiiricle,  the  inflow  causes  that  chamber  to  dilate 
(auricular  diastole).  As  soon  as  this  auricle  is  filled,  the  chamber 
contracts,  (auricular  sj'stole)  and  forces  the  blood  through  the  left 
auriciilo-ventricular  orifice  into  the  left  ventricle.  If  now  the  mitral 
valve  has  been  affected  by  disease  in  one  of  the  ways  set  down,  so  that 
the  orifice  is  narrowed  and  the  flow  obstructed,  the  current  no  longer 
passes,  silently  and  swiftly,  thi-ough  the  gateway  to  its  ventricle. 


184  THE    HKAHT 

The  obstruction  causes  the  eniptyinfr  jiroeess  to  lie  impeded  and  there- 
fore prolonyed,  aud  the  passage  of  the  blood  is  accompanied  by  a 
nnirmur,  which  has  its  greatest  intensity  in  the  apex  region  aud  which, 
in  point  of  time,  occurs  during  tlie  auricular  systole,  that  is,  before 
tin  apex  impact.  Such  a  niurnuu-  denotes  mitral  stenosis,  and  is  so 
named.  It  begins  when  auricular  systole  begins  and  ends  with  or 
before  the  completion  of  that  act.  It  occurs  while  the  blood  is  being 
expelled  from  the  auricle  and  while  the  ventricle  is  still  passive,  but 
it  frequently  results  in  a  prolongation  of  the  auricular  contraction. 
Being  produced  by  the  blood  Howing  in  its  natural  direction  it  is 
spoken  of  as  a  direct  murmur,  in  contradistinction  to  murnuirs  arising 
when  the  blood  flow  is  in  a  direction  contrary  to  its  natural  course, 
such  nuirmurs  being  named  indirect  nuirmurs.  Special  attention  is 
directed  to  the  fact  that  this  nuu-mur  may  be  distinctly  audible  only 
when  the  patient  is  lying  down,  disappearing  when  he  sits  or  stands. 
Although  this  murmur  occurs  during  ventricular  diastole,  it  is  not 
to  be  understood  that  it  is  audible  during  the  entire  period  of  the 
ventricular  dilatation,  although  blood  is  flowing  passively  into  the 
cavity  during  the  whole  of  that  act.  Ventricular  diastole  closes  with 
auricular  systole,  and  the  added  impetus  given  to  the  current  by  this 
contraction  of  the  auricle  may  be  necessary  to  impart  sufficient  force 
to  the  stream  to  produce  the  nuirmur.  The  auricular  contraction  is 
inaudible,  but  is  immediately  followed  by  the  ventricular  contraction, 
which  produces  the  first  sound  of  the  heart.  Since  the  murmur  is 
generated  innnediately  before  this  latter  contraction  or  systole,  it  is 
CM  lied  presystolic,  which  distinguishes  it  from  those  murmurs  whose 
dni'ation  is  that  of  the  entire  diastolic  period.  The  special  point  re- 
garding its  tempo  is  that  it  is  not  heard  immediately  after  the  second 
sound  of  the  heart,  but  immediately  before  the  first  sound. 

With  or  without  encountering  obstacles  in  its  path  the  blood  from 
the  left  auricle  now  reaches  and  distends  the  left  ventricle  (ventric- 
ular diastole),  whose  contraction  immediately  succeeds  its  distention 
(ventricular  systole).  In  the  healthy  heart  the  only  escape  for  the 
current  imprisoned  by  the  closure  of  the  mitral  gate  is  through  the 
open  aortic  valve.  If,  however,  disease  has  wrought  changes  which 
inhibit  the  perfect  closure  of  the  mitral  leaflets,  when  the  blood  surges 
against  them  during  the  ventricular  contraction  they  will  not  suffice 
to  stop  its  flow,  but  will  permit  a  portion  of  the  fluid  to  pass  back- 
wai'ds  and  re-enter  the  left  auricle.    This  back-How  is  furthei-  aided  bv 


PLATE  XI. 

THE    VALVULAR    AREAS. 


Red  Circle,  Mitral  Area. 
Triangle,  Tricuspid  Area. 
The  Aortic  Area  in  black  dots. 


P.     Pulmonary  Area. 


THE    HEAET  185 

tlie  slight  negative  pressure  existing  in  the  auricle  during  that  period 
of  the  cardiac  cycle.  The  valve  permitting  this  return  flow  just 
described  is  said  to  be  incompetent,  or  insufflcient,  and  the  reverse 
current  is  called  regurgitation.  In  this  ease  it  is  mitral  regurgitation. 
This  phenomenon  is  indicated  also  by  an  accompanying  murmur,  which, 
in  its  beginning,  is  synchronous  with  ventricular  systole, — that  is  to 
say.  the  apex  impact  and  the  carotid  pulse,  and  accords  with  the  first 
sound  of  the  heart;  or  it  immediately  succeeds  that  sound  and  pro- 
longs it,  ending  between  the  first  and  second  heart  sounds.  It  is 
the  most  common  of  the  valvular  defects.  The  preceding  murmur  may 
exist  as  an  independent  entity,  but  is  more  often  associated  with  the 
present  one. 

TRICUSPID  MURMURS. 

The  right  ventricle  acts  in  unison  with  the  left,  its  systole  and 
diastole  are  at  one  with  its  fellow.  The  tricuspid  valve  bears  the  same 
physiologic  relation  to  the  right  heart  that  the  mitral  valve  does  to 
the  left.  Except  for  the  number  of  its  leaflets,  its  anatomic  construc- 
tion is  similar,  that  is,  the  edges  are  joined  to  the  delicate  chordiE 
tendinete  which  limit  its  motions;  hence  it  is  subject  to  the  same  ail- 
ments as  its  fellows,  but  for  some  unknown  caiise  is  less  often  visited 
by  these  afflictions.  The  tempo  of  the  murniiirs  which  arise  in  con- 
nection with  disorders  of  this  valve  will  coincide  in  all  respects  with 
those  of  the  mitral.  Hence  tricuspid  stenosis  will  be  presystolic 
(auricular-systolic),  and  tricuspid  insufficiency  will  be  accompanied  by 
a  regurgutation  which  takes  place  during  right  ventricular  sys- 
tole (v.  s.) 

Tricuspid  regurgitation  seldom  exists  as  an  independent  disease,, 
except  as  the  result  of  a  congenital  defect.  It  is  prone  to  be  one  of 
the  later  complications  of  mitral  disease. 

The  stenosis  is  still  rarer  thau  the  incompetency. 

Tricuspid  murmurs  are  quite  distinct  and  superficial,  almost 
never  heard  higher  than  the  third  rib,  hence  are  not  easily  overlooked, 
nor  are  they  apt  to  be  misinterpreted. 

AORTIC  VALVE  IMURMURS. 

The  outflow  of  blood  through  the  aortic  semilunar  or  sigmoid 
valve  takes  place  during  the  systole  of  the  venti-icles.  Alterations 
occurring  at  this  orifice  of  such  a  nature  as  to  ofiler  an  impediment 
to  the  outward  current,  such  as  narrowing  of  the  passage,  give  rise 


18H  Tin:   iikaht 

to  a  iimrnuir  which  is  syiK-hriiiKUis  witli  tiu'  ;i\ir\  hral  and  rdUows 
the  first  sound  of  tiir  hoart  as  a  prolonjjation  ol'  thai  sound.  The 
murnini-  will  then  he  vi'iitrieiihir-systolie  (.v.  s. ).  and  tiic  character  of 
the  obstruction  will  be  stenosis. 

If,  by  reason  of  enlargement  of  the  aortic  riiiL;-  or  owiiii;'  to  defects 
ali-eady  expounded,  the  valves  are  unable  to  prevent  the  retlu.x  of  the 
current  which  closes  tliem  back  into  the  ventricular  chamber,  then 
this  liack'wnj'd  How  or  i'e<iurt;itation  of  lilood  will  also  enn:ender  a 
iiiurnuir  which  succeeds  immedialely  ii]ion  the  ineffectual  elosui'e  of 
the  valves,  that  is  to  say  dui-inu'  the  jieriod  of  diastoh  of  the  ven- 
tricles (v.  d.)  The  murmur  so  produced  is  usiialy  a  long;-drawTi, 
soft  souffle  which,  as  an  index  of  disease,  is  the  most  I  rustworthy  of 
all  the  adventitious  heart  sounds.  Such  a  sound  may  replace  or 
obscure  the  second  aortic  heart  sound,  since  in  some  cases  the  stiffened 
segments  make  little  or  no  efforts  at  closure,  and  the  backwai'd  flow 
berjiiis  with  the  beginning  of  diastoh . 

A  consideration  of  what  is  taking  place  in  the  cardiac  chambers 
at  this  time  will  enable  us  better  to  understand  the  mechanism  of  this 
murmur.  While  the  semilunar  valves  are  closing,  the  ventricles  are 
dilating  with  the  in-take  of  blood  from  the  auricles,  which  act  con- 
tinues not  only  during  the  time  when  the  second  sound  is  produced, 
but  subsequently  thereto  until  these  chambers  are  filled,  when  another 
systole  empties  them :  hence  the  murmur  ceases  before  systole. 

In  many  instances  the  defect  of  the  aortic  valve  produces  a  double 
murmur,  a  combination  of  the  two  conditions  described  (v.  s.  +  v.  d.). 
Their  relation  in  point  of  precedence  will  be  described  later. 

THE  Pl'L^ilOXARY  VALVE  MURMURS. 

Acquired  lesions  of  the  pulmonary  valve  are  pathologic  curiosi- 
ties. Even  congenital  lesions  are  rare.  .Muinuirs  are  often  heard 
in  the  pulmonary  region,  but  most  of  these  are  either  false  or  func- 
tional murmurs,  or  are  transmitted  from  other  seats,  the  areas  being 
somewhat  anomolous.  Attention  is  directed  to  this  condition  of  affairs 
in  speaking  of  mitral  affections. 

However,  two  lesions  of  the  pulmonary  leaflets  are  recognized, 
stenosis  and  instifificiency.  The  first  should  give  rise  to  a  murmur 
synchronous  with  the  emptying  of  the  right  ventricle,  which  is  there- 
fore ventricular  systolic  (v.  s.)  ;  and  the  second,  when  manifested  by 
a  definite  mui'mur.  would  be  in  time  ventrieulai'-diastolie  (v.  d.).  but 


THE    HEART  187 

these  are  perhaps  the  rarest  of  all  the  cardiac  murmurs  aud  the 
3)hysician  should  be  wary  of  asserting  on  insufficient  evidence  the 
presence  of  the  lesion  which  seemingly  gives  rise  to  such  a  murmur. 

FALSE  MURMURS. 

The  name  of  cardio-pulmonary  murmurs  is  given  to  false  mur- 
murs which  closely  resemble  the  sounds  produced  by  organic  disease 
of  the  valves,  but  which  in  reality  are  produced  outside  the  heart  as 
the  result  of  disease  within  the  thorax,  or  of  neighboring  organs. 

The  chief  causes  of  such  extra-cardiac  murmui-s  are  pressure 
exerted  upon  the  heart,  or  displacement  of  the  organ,  as  the  result 
of  disease  of  the  pleura  or  the  lung,  effusion  into  the  pericardiac  sac, 
abdominal  disease  causing  ixpward  pressiu'e,  changes  in  the  peri- 
cardium or  in  the  lappet  of  lung  which  overlaps  the  heart. 

Cavity  contraction  of  the  left  lung  with  upward  displacement 
is  described  under  tuberculosis.  This  displacement  gives  rise  occa- 
sionally to  a  systolic  murmur  heard  at  the  second  or  third  interspace, 
which  may  be  mistaken  for  mitral  regurgitation  or  even  aortic  dis- 
ease. The  displacement  and  the  rareness  with  which  valvular  dis- 
eases are  found  in  pulmonary  tuberculosis  should  correct  the  error. 

In  a  like  manner  a  murmur  is  produced  by  disease  of  the  left 
pleura.  The  sequela-  of  this  disease  are  thickening  of  the  membrane, 
partial  collapse  of  the  lower  lobe  of  the  hmg  and  contraction  of  the 
chest  wall.  The  murmur  is  systolic,  caused  by  the  heart's  impact 
displacing  the  air  from  the  larger  bronchi.  This  murmur  is  heard  in 
the  axilla,  around  to  the  left  scapular  angle  as  well  as  at  the  apex 
and  in  the  mouth.  The  latter  quality,  in  conjunction  with  the  history, 
aids  in  diagnosis  from  organic  mitral  murmurs  which  are  never  heard 
in  the  mouth  or  over  the  trachea.  Abdominal  pressure,  as  in  enlarge- 
ments of  the  liver,  and  abdominal  dropsies,  have  caused  systolic  mur- 
murs which  disappear  after  paracentesis. 

Pleural  effusions,  accompanied  by  displacement  of  the  heart, 
especially  left-sided  effusions,  may  be  accompanied  by  a  loud  systolic 
murmur  heard  at  both  base  and  apex.  It  disappears  after  removal 
of  the  fluid.  Osier  and  other  writers  call  attention  to  the  frequency 
of  a  systolic  murmv;r  heard  about  the  cardiac  apex  in  tuberculous 
sub.jects.  The  murmur  resembles  mitral  regurgitation  and  is  caused 
by  the  displacement  of  the  air  in  the  partially  consolidated  lappet,  by 
"the  cardiac  impact,  as  in  the  case  of  pleurisy.     It   is   always  more 


188  THE     liKAUT 

distinct  diiriiiy;  uxpiratioii,  iiiid  disappears  when  the  breath  is  hehl 
after  a  full  inspiration  or  when  the  patient  lies  down.  Heard  at 
the  apex  and  in  the  left  axilla,  yet  its  most  common  seat  and  point 
of  greatest  intensity  is  in  the  second  left  intercostal  space  about  two 
inches  from  the  sternum.  In  doubtful  eases  of  tuberculosis  the  pres- 
ence of  this  murmur  at  the  point  indicated  is  strong  evidence  of  con- 
solidation.    (See  Pulmonary  Tuberculosis.) 

Changes  in  the  pericardium  resulting  from  previous  inflamma- 
tion are  frequent  causes  of  murmurs  which  are  heard  over  an  exceed- 
ingly limited  area,  viz.,  the  sixth  left  interspace  and  over  the  seventh 
rib  close  to  the  ensiform  cartilage,  where  the  right  ventricle  is  in 
contact  with  the  chest  wall.  The  sound  is  very  superficial,  shori, 
sharp,  systolic,  never  rough  or  blowing.  The  sound  often  resembles  a 
reduplication  of  the  first  heart  sound.  It  may  disappear  wlien  tin- 
I)atient  lies  down,  lint   not  invariably. 

False  ninrnnns  of  this  class,  cardiorespiratory,  often  center 
around  the  pulmonary  valve.  In  time  they  arc  systolic  and  are  fre- 
quently to  be  heard  in  thin-chested  individuals  and  children.  They 
ai-e  best  heard  during  forced  expiration  with  the  sub.iect  recumbent. 
They  are  present  after  great  exertion  or  excitement  and  during  con- 
valescence from  acute  diseases. 

The  pulmonary  area  is  a  favoi-ite  seat  for  the  ameuiie  murnun-s. 

Lastly  emphysema,  when  it  causes  downward  displacement,  is 
frequently  accountable  for  a  murmur  which  is  at  one  with  the  above 
described  pei'icardial  murmur  in  time,  ciuality  and  location. 

It  will  be  seen,  therefore,  that  the  mere  presence  of  a  murnnir, 
as  has  been  said  previou.sly,  by  no  means  is  indicative  of  organic 
valvular  disease.  Neither  is  the  inability  to  discover  such  a  murmur 
positive  grounds  for  its  exclusion.  The  diagnosis,  therefore,  should 
oe  based  on  the  ensemble  of  physical  signs  and  especially  on  the  con- 
secutive changes  which  the  disability  produces  in  the  heart,  sooner  or 
later,  in  almost  all  cases  of  grave  disease.  Attention  to  these  and  the 
following  points  will  usually  lead  to  a  eoi-rect  interpretation  of  the 
conditions. 

W.  Oilman  Thompson  says  that  false  and  functional  mui-nmrs 
are  always  systolic,  never  dia.stolic.  While  we  are  not  prepared  to 
agree  fully  with  this  statement,  nevertheless  it  must  be  admitted  that 
the  vast  majority  of  them  is  systolic. 

Osier  lavs  down  the  following  rules: — - 


$EfTUV\ 


PLATE  XII. 

Relation  of  the  Heart,  its  vessels  and  valves,  to  the  Sternum  and  Cartilages. 
Note  relationship  of  Aortic  and  Mitral  Valves. 


THE     HE-^J^T 


189 


(1)  In  thin,  nervous  children  a  systolic  murmur  of  soft  quality 
is  extremely  common  at  the  base,  particularly  at  the  second  left  costal 
cartilage,  and  is  probably  of  no  moment. 

(2)  A  systolic  murmur  of  maximum  intensitj'  at  the  apex,  and 
heard  also  along  the  left  sternal  margin,  is  not  uncommon  in  anaamic, 
enfeebled  states,  and  does  not  necessarily  indicate  either  endocarditis 
or  insufficiency. 

(3)  A  murmur  of  maximum  intensity  at  the  apex,  with  rough 
quality,  and  transmitted  to  the  axilla  or  angle  of  the  scapula,  indicates 
an  organic  lesion  of  the  mitral  valve,  and  is  usuallj"  associated  with 
signs  of  enlargement  of  the  heart. 

(4)  "When  in  doubt  it  is  much  safer  to  trust  to  the  evidence  of 
the  eye  and  hand  than  to  that  of  the  ear.  If  the  apex  beat  is  in  the 
normal  position,  and  the  area  of  dullness  not  increased  vertically  or 
to  the  right  of  the  sternum,  there  is  probably  no  serious  valvular 
lesion. 


Organic  Murmurs. 

1.  Quality  oftenest  blowing. 

2.  Oftenest     exactly     synchro- 
nous with  svstole  or  diastole. 


3.  Definite  seat  of  maximum 
intensity  marked  b}^  anatomic 
point.  Areas  of  propagation  defi- 
nite. 


4.  Little  affected  by  change  in 
position  or  by  holding  breath.  In- 
tensity increased  by  forced  ex- 
piration. Some  heard  only  in  re- 
cumbency. 

5.  If  heard  in  mouth  or  trachea 
is  aortic  stenosis  or  aortic  aneu- 
rysm.   Mitral  murmurs  never. 

6.  Pulmonary  engorgement 
conunon. 


False  Blvrmurs. 

1.  Often  superficial,  quality 
frictioiial. 

2.  Time  not  synchi'onous 
with  beginning  systole  or  diastole. 
Jlay  precede  or  follow.  Are  rare- 
ly diastolic. 

3.  Seat,  point  of  maximum  in- 
tensity varies.  Often  heard  at 
both  base  and  apex  without 
change  in  quality.  Area  of  propa- 
gation irregular,  not  coincident 
with  corresponding  organic  area. 

4.  Many  disappear  when  pa- 
tient is  recumbent  or  upon  sus- 
tained full  inspiration. 


5.  Many     heard  in  mouth,  es- 
pecially "air  imi)act"  murmurs. 

6.  Pulmonary  engorgement  ab- 
sent.   Jlay  be  ana?mia. 


SECTION  X. 

DISEASES  OF  THE  HEART. 

PERICARDITIS. 

Dc/iiiilioii.  Pericarditis  is  an  iiirlanimatory  process  attacking  the 
serons  covering  of  the  heart  and  its  reflection  upon  the  inner  surface 
of  the  pericardial  sac.  A  primary  or  idiopathic  form  is  recognized, 
but  is  i*are.  Traumatic  pericarditis  may  occur.  Secondary  forms 
arise  in  connection  with  rheumatism,  tonsillitis,  septic  and  tuberculous 
infections,  scarlet  fever  and  occasionally  after  other  eruptive  fevers 
and  in  the  course  of  goiit  and  Bright  "s  disease.  It  occurs  by  extension 
in  eases  of  inflammation  of  contiguous  sti'uctures,  especially  of  the 
heart,  arteries  and  bronchial  glands.  Pleurisy,  morbid  growths,  sup- 
puration and  occasionally  other  rarer  causes  are  accountable  for  its 
presence. 

Forms. — The  disease  may  be  divided  conveniently  into  three 
forms : 

1.  Plastic  or  dry  pericarditis. 

2.  Pericardial  effusion. 

3.  Chronic  or  adhesive  pericarditis. 

The  plastic  or  dry  form  may  constitute  the  first  stage  of  the  suc- 
ceeding varieties,  but  one-half  of  the  cases  do  not  advance  beyond  the 
dry  form. 

Plastic  pericarditis  is  charactei'ized  by  the  small  amount  of  fluid 
exudate,  an  amount  too  small  to  be  recognized  by  physical  signs. 
When  caused  by  tuberculosis  it  may  result  in  progressive  chronic 
thickening  without  effusion. 

Inspection  gives  no  signs.  Palpation  may  reveal  a  distinct 
friction  fremitus,  best-marked  over  the  central  and  most  superficial 
parts  of  the  heart.    The  sign  is  oftener  absent  than  present. 

Auscultation  reveals  the  friction  sound,  one  of  the  most  impor- 
tant, as  well  as  one  of  the  most  distinctive,  of  physical  signs.  The 
sound  originates  from  the  rubbinEr  together  of  the  two  roughened  sur- 


DISEASES    OF    THE    HE.VRT  191. 

faces  of  the  pericardium,  hence  is  a  superficial  to-and-fro  sound  heard, 
directly  under  the  ear.  Although  caused  by  the  systole  and  diastole 
of  the  heart,  the  rubbing  is  not  perfectly  synchronous  therewith,  being 
usually  more  prolonged  than  these  sounds.  It  may  be  single,  or,  on 
the  other  hand,  the  rhythm  may  be  miiltiple  or  galloping.  Galloping 
rhji;hm  is,  however,  more  characteristic  of  the  adherent  form. 

The  sound  is  rough,^  grating,  rubbing,  creaking,  or  it  may  be  loud 
and  rasping.  The  creaking  character  has  been  likened  by  the  French 
to  that  of  new  leather  and  is  termed,  bruit  de  cuir  neuf.  It  is  never 
blowing;  never  conducted  in  the  direction  of  the  blood  currents; 
never  heard  over  wide  areas.  It  may  be  intensified  by  bending  the  pa- 
tient forward.    It  is  influenced  by  respiration  and  changes  of  position. 

In  some  cases  the  sound  is  best  heard  over  the  apex  or  over  the 
base,  instead  of  in  the  area  given. 

Pericardial  friction  is  not  a  phenomenon  of  long  duration  and  dis- 
appears as  soon  as  liquid  accumulates  within  the  sac. 

Diagnosis.  The  only  probable  mistake  which  is  apt  to  occur  in 
the  diagnosis  of  diy  pericarditis  is  to  confuse  a  pleuro-pericardial 
friction  soimd  with  a  pure  pericardial  friction.  The  former  is  com- 
mon in  phthisis  and  pleuro-pneumonia.  Time  will  usually  resolve  the 
difficulty  since  the  pi;re  pericardial  sounds  disappear  after  a  brief 
interval,  while  the  others  may  reinain  for  protracted  periods.  Pleuro- 
pericardial  sounds  are  not  as  a  rule  located  over  the  anterior  and 
superficial  parts  of  the  heart.  Being  caused  by  roughening  in  the  left 
ventricular  region,  the  sounds  are  confined  to  the  left  border  of  that 
organ. 

Holding  the  breath  does  not  affect  the  pericardial  sound,  but 
often  causes  a  cessation  of  the  pleuro-pericardial,  particularly  holding 
the  breath  after  a  deep  inspiration.  The  respiratory  rhji;hm  further 
affects  the  last  named  by  increasing  its  intensity  during  expiration 
and  diminishing  it  with  inspiration.  It  is  less  superficial  and  not  apt 
to  be  a  to-and-fro  sound. 

Double  aortic  murmurs  are  propagated  into  the  neck,  are  perma- 
nent, not  affected  by  respiration  or  position  and  are  accompanied  by 
a  wholly  different  train  of  sj-mptoms,  which  should  prevent  confusion. 

PERICARDIAL  EFFUSIONS. 

The  signs  vary  with  the  amount  of  the  effusion.  If  considerable, 
inspection  will  show  precordial  bulging,  especially  in  children,  widen- 


192 


DISEASES    OF    THE    UEART 


iug  aud  obliteration  of  the  interspaces  and  a  wavering,  undulating  im- 
pulse. In  smaller  effusions  the  impulse  is  tumiUtuous.  As  the  amount 
of  fluid  increases  the  lieart  rcccclcs  fi-cini  Ihc  i-hcsl  wall  and  the  iinpulse 
becomes  invisible. 

The  veins  of  the  neck  sliow  distention,  Thd'c  is  often  a  promi- 
nence in  the  epigastrium  due  to  the  downward  displacement  of  the 
]iver.    QDdema  of  the  chest  wall  may  be  present. 


Fig.    43 — Showing    area    of    dullness    in    pericardial    effusion. 

Mensuration.  The  expansion  of  the  left  lung  is  diminished,  the 
left  lateral  circumference  is  increased. 

Palpation.  The  apex  beat  gradually  becomes  less  and  less  distinct 
and  disappears.  After  it  can  no  longer  be  felt  in  the  fifth  interspace 
it  still  may  be  palpable  in  the  fourth.  Friction  fremitus  has  now  dis- 
appeared over  the  right  ventricle,  but  may  persist  longer  over  the  base 
of  the  heart.    Fluctuation  can  very_rarely  be  detected. 

Percussion  furnishes  the  most  sti'iking  symptoms  of  effusion.  As 
the  fluid  accumulates  the  area  of  cardiac  dullness  enlarges  in  all  direc- 
tions.    The  edges  of  the  lungs  are  pushed  aside,  even  the  diaphragm 


DISEASES    OF    THE    HEART  193 

and  livei"  are  depressed.  The  area  is  now  rudely  triangular  or  pear- 
shaped  with  its  base  across  the  sixth  or  even  the  seventh  interspace,  its 
apex  or  stem  pointing  to  the  inner  end  of  the  left  clavicle.  In  very 
large  effusions  dullness  may  extend  from  nipple  to  nipple,  which  is 
never  the  case  in  cardiac  hypertrophy.  This  dullness  is  rendered  the 
more  striking  and  abrupt  by  the  hyper-resonance  of  the  neighboring 
compressed  limg. 


Fig.   44 — Effusion   into   pericardia!   sac,  shading   insensibly  into   the   diaphragm. 

Rotch  's  sign  of  effusion  is  dullness  in  the  fifth  interspace  on  the 
right  side.  E wart's  sign  is  dullness  or  impaired  resonance  posteriorly 
above  the  angle  of  the  left  scapula.  Both  are  valuable.  Pressure 
upon  the  left  lung  may  impair  the  pubnonary  percussion  note,  ren- 
dering it  flat  or  vesiculo-tympanitic  ( Skoda 's  resonance).  The  change 
is  most  marked  in  the  left  axillary  region  as  high  up  as  the  nipple.  It 
is  altered  by  changes  in  the  position  of  the  patient,  as  is  also  the  area 
of  dullness  at  the  scapular  angle:  both  may  disappear  when  the  pa- 
tient leans  forward. 

Auscultation.    With  the  increase  in  the  effusion  the  heart  sounds 


1114  nisKASK-;  or    riiK.   iii-.Aur 

hcciiiiic  ui  ;ulii;illy  w  (■;il<i'n(Ml  and  iinirilcd  and  liinilly  arc  almost  iiiau- 
dililc.  Fiictioii  sounds  ina>-  persist  over  the  base  of  the  heart  after 
thc\  liave  disappeaird  IVoni  over  the  ventricular  area,  or  may  be  heard 
when  tlie  patient  is  erect,  disappearing  when  he  lies  down.  Generally 
the  heai't  sounds  may  be  heard  at  the  top  of  the  sternum  after  they 
have  hci-onii'  inaudible  over  the  prajcordia. 

The  heart's  action  is  increased  and  irregular.  A  systolic  nnirnnir 
may  be  present  and  give  ri.se  to  the  erroneous  diagnosis  of  mitral  valve 
disease,  and  the  pulmonary  second  sound  may  be  manifestly  accen- 
tuated. The  breathing  sound  icfei-red  to  above,  heard  in  the  axillary 
region,  is  feeble  or  even  1nl)nlar  in  case  of  sntificient  pressure.  The 
i|nalit\'  idiaiigcs  somewhat    witli  variations  in  the  position  of  the  jia- 

tiellt. 

Diiif/iiiisis.  The  diagnosis  presents  many  difficulties,  in  spite  of 
the  well-marked  signs  set  down.  The  disease  is  often  overlooked  and 
even  unsuspected  when  the  sac  is  filled  to  I'epletion  with  fluid.  In 
cases  of  rheumatism,  esi)ecia]ly  in  children,  the  heai-t  should  be  exam- 
ined daily. 

The  condition  which  most  closely  rcscmiiles  elTusion  is  dilatation 
of  the  heart.     The  followinu'  are  the  |)rincipal  jjoints  of  difference: 
Dilataliuii.  Effusion. 

Inspection.    Impulse  visible  ex-  Impulse  invisible, 

eept  in  stout  persons.    AVavy. 

Palpation.     Impulse    felt.     Tn-  Impulse  not  felt  when  ei'ect. 

changed   by   forward    inclination  .May  be   paliiable  wlien  itatieii! 

of  patient.  leans  forwai'd. 

Percu.ssion.     Dull  area  not  ti'i-  Dull  in  tifth  and  even  sixth  in- 

angular,  increases  downward  and  tersjiaces  on  both  .sides:  is  trian- 
to  left  in  mitral  stenosis,  in  other  gular-shaped,  reaches  high  as  see- 
forms  it  never  reaches  so  high  on  ond  rib  on  left  of  sternum :  up- 
left  of  sternum.  per  limit  may  shift    with  change 

of  position. 

Auscultation.       Heart     sounds         Sounds  ilistant  and  nni  lied. 
valvular  and  clear,  especially  sec- 
ond sound. 

Dyspnoea  less  urgent  and  inHu-  Dys])n(ea   not   so  influenced, 

enced  by  exertion. 

Slow  development,  no  pain,  no         Tfapid        development,        pain, 
fever.  fever. 


DISEASES    OP    THE    HEART  195 

Tlie  most  striking  point  of  dift'erence  is  that  dilatation  never 
reaches  a  degree  in  which  the  dull  area  simulates  that  of  effusion, 
without  the  presence  of  visible  pulsation  and  never  produces  Skodaie 
resonance  in  the  axillary  region. 

CHRONIC  PERICARDITIS;   ADHESIVE  PERICARDITIS. 

The  signs  are  most  pronounced  in  children,  in  whom  the  condition 
is  prone  to  remain  as  a  memento  of  rheumatism.  The  disease  ordi- 
narily leads  to  dilatation  and  hypertrophy  with  insufiicieney  of  an  ex- 
treme grade,  and  the  physical  signs  ultimately  become  the  signs  of  that 
affection.    Other  manifestations  vary  exceedingly. 

Inspection.  The  priecordia  in  the  post-effusion  stage  is  retracted, 
espeeiallj'  in  young  subjects :  later,  bulging  and  asymmetry  succeed 
owing  to  the  cardiac  enlargement.  The  impulse  is  diffuse,  multiple  or 
wavy,  increased  in  area,  often  extending  from  the  third  to  the  sixth  rib 
and  beyond  the  nipple.  It  may  be  displaced  in  any  direction,  espe- 
cially downward  or  to  the  right.  Each  systole  may  produce  a  retrac- 
tion of  the  chest  wall,  a  valuable  sign  of  adherence  when  present. 
Adhesion  to  the  diaphragm  gives  rise  to  a  systolic  tugging  at  the  points 
of  attachment,  particularly  at  the  seventh  and  eighth  ribs  in  "the  left 
antero-lateral  region,  and  behind  between  the  eleventh  and  twelfth 
ribs  on  the  left  side.  This  visible  retraction  of  the  chest  wall  behind 
with  each  sj'stole  is  known  as  Broadbent  's  sign.  In  such  attachments 
the  diaphragm  does  not  descend  with  inspiration,  hence  the  natural 
respiratory  excursion  of  the  epigastrium  is  absent.  The  same  restric- 
tion of  diaphragmatic  movement  occurs,  however,  in  pleuritic  effusions 
and  emphysema  above,  and  in  ascites,  abscess  or  tumor  beneath  the 
structure ;  hence  the  sign  must  not  be  interpreted  as  invariably  indi- 
cating adhesions,  as  is  sometimes  stated.  The  diastolic  collapse  of  the 
cervical  veins  due  to  their  sudden  emptying,  with  expansion  of  the 
chest  wall,  is  known  as  Friedreich's  sign.  Osier  says  its  significance 
is  of  little  moment. 

An  important  sign  related  to  adherent  pericardium,  but  by  no 
means  Confined  to  that  disease,  is  known  as  Litten's  sign,  described 
by  him  in  1892  and  denominated  "The  Diaphragm  Phenomenon."  It 
is  a  visible,  undulating,  ascending  and  descending  wave  or  shadow  to 
be  seen  with  respiration  between  the  sixth  intercostal  space  and  the 
free  border  of  the  ribs,  crossing  the  latter  at  an  acute  angle.  It  is 
produced  by  a  stripping  off  of  the  diaphragm  from  the  chest  wall. 


196  msEASKs  (IF  Till';  heart 

and  is  synclironous  witli  tlu'  iiiuvciiiciits  of  the  midriff.  It  is  most 
apparent  iu  the  axillary  or  parasternal  line  when  viewed  in  a  strong 
light.  With  the  patient  recumbent,  the  arms  extended  above  the  head, 
lie  is  directed  to  take  a  long:  bi'eath.  which  must  be  abdominal  and  not 
costal.  Litteu  also  states  that  by  laying  the  patient  on  his  belly  the 
wave  is  sometimes  seen  on  deep  breathing  posteriorly  in  the  lowei- 
thoracic  zone.  It  may  be  seen  in  a  good  artificial  liglit  and  may  some- 
times be  noticed  with  the  patient  standing  or  sitting,  as  well  as  when 
lying  down.  The  sign  is  absent  in  very  young  children  and  changes 
its  character  in  old  age  owing  to  the  calcification  of  the  cartilages.  It 
is  a  common  phenomenon  of  health  and  is  present  in  over  ninety  per 
cent,  of  individuals,  in  fact  in  all  cases  where  the  dia])hrai;in  a.'ieeiids 
and  descends  normally  with  respiration. 

The  normal  .shadow  is  about  three  inches  in  extent  (6-7  em. — Lit- 
ten)  and  is  more  marked  in  men  than  in  women  and  ehildren.  Wii  mi 
equal  and  unbroken  on  both  sides  it  indicates  ikuhuiI  iiulinonie  condi- 
tions or  healthy  lungs. 

It  is  exaggerated  in  both  health  and  di.sease  when  the  respirations 
are  uniformly  increased.  Exaggeration  on  one  side  means  vicarious 
I'espiration  on  that  side  and  diminished  function  on  the  opposite.  It  is 
diminished  on  both  sides  equally  in  asthma,  emphysema  and  other 
conditions  which  diminish  uniformly  the  respiration  volume.  In  such 
cases  Litten  says  the  sign  is  more  apparent  posteriorly  than  anteriorly. 
It  is  diminished  on  one  side  in  the  unilateral  affections  of  the  lung  or 
pleura,  especially  unilateral  tuberculosis,  of  which  it  is  an  early  and 
reliable  sign,  in  pleurisy,  in  hypertrophy  of  the  heart  and  in  peri- 
cardial effusions.  Pleural  and  pericardial  adhesions  break  the  wa^e 
in  a  variety  of  ways.  ^Yheu  the  adhesions  are  extensive  the  wave  is 
absent.  It  is  ab.sent  in  advanced  tuberculosis  and  other  diseases  accom- 
panied by  considerable  consolidation,  and  in  cases  of  collection  of  air 
or  fluids  within  the  pleural  sac. 

Accumulations  of  fluid,  tumurs  lielow  the  diaphragm,  and 
advanced  pregnancy  mechanically  inhibit  the  shadow,  and  thus  its 
absence  serves  to  locate  them.  Litten  mentions  that  it  is  present  in 
subphrenic  abscess. 

Palpaiioii.  The  diastolic  shock  or  rebound  of  the  heart  is  felt 
when  the  hand  is  placed  over  the  pru'cordia.  This  is  regarded  as  the 
most  positive  sign  of  adherent  pericardium.  Systole  may  cause  a 
retraction  of  the  chest  wall,  to  be  followed  by  the  shock.     The  apex 


PLATE  XIII. 


ABC  The  Area  of  Dullness  in  Pericardial  Effusion  as  shown  by 
the  X-Ray  Examination.  Diaphragm  pushed  down. 
Heart  Apex  at  A. 


DISEASES    OF    THE    HE.VET  19  i 

position  does  not  change  to  the  left  as  in  the  normal  heart,  when  the 
patient  is  turned  on  the  left  side,  owing  to  the  adhesions. 

Percussion.  The  area  of  cardiac  dullness  is  increased  upward  and 
to  the  left,  reaching  in  extreme  cases  the  first  interspace.  Adherence 
between  the  pericardium  and  the  pleura  may  prevent  the  left  and 
upper  margin  of  the  dull  area  from  changing  ^vith  deep  breathing, 
as  pointed  out  by  Williams.  Osier  finds  that  considerable  adhesion 
of  pleura  to  pericardium,  or  of  pleura  to  chest  wall,  none  the  less 
■  allows  almost  unrestricted  motion. 

Auscidfatiou.  The  signs  may  be  negative.  At  best  they  are 
uncertain.  The  heart  rhj'thni  may  be  galloping  or  foetal.  A  systolic 
OT-  presystolic  murmur  is  often  present,  heard  over  the  apex.  The 
signs  of  dilatation  and  insufBciency  ultimately  predominate  when  that 
condition  becomes  paramount. 

AuxiUary  signs.  That  pericarditis  is  a  painful  disease  is  a  wide- 
spread error.  Pain  is  severe  in  a  few  eases,  in  others  it  is  absent  or 
only  slight.  It  may  be  referred  to  the  xiphoid  cartilage.  Fever  is 
generally  present  but  is  not  high.  In  intercurrent  cases  it  augments 
the  existing  temperature.  In  rheumatism  hyperpyrexia  may  oecijr. 
Dyspnoea  of  slight  grade  occui's  in  the  plastic  form :  with  eifiision  it  is 
goierally  sufficient  to  draw  attention  to  the  heart. 

The  puLse  is  rapid  and  small.  In  adherent  eases  the  imlsv.s  pam- 
dnxus  of  Kussmaul  is  a  symptom  of  note.  It  consists  of  an  increase  in 
frequency  with  gradual  weakening  and  even  disappearance  of  the 
piilse  during  inspiration.    Initial  chiU  is  occasional. 

hydropericardiu:m. 

During  the  course  of  those  diseases  which  produce  general 
anasarca  or  dropsy,  fluid  may  accumulate  within  the  pericardium  in 
considerable  ciuantitj*.  The  disease  is  then  known  as  hydropericar- 
dium.  The  condition  is  tmaecompanied  by  inflammation  of  the  sac. 
but  occurs  in  the  course  of  such  chronic  diseases  as  nephritis:  the 
valvular  heart  affections,  cirrhosis  of  the  liver,  cancer,  and  tubercu- 
losis. The  efliusion  is  sometimes  stained  red.  Pleural  effusions  may 
be  complicated  by  transudate  into  the  sac.  in  which  ease  one  or  the 
other  effusion  is  very  apt  to  be  overlooked.  Occasionally  the  fluid 
collects  after  scarlet  fever. 

The  physical  signs  are  those  given  under  pericarditis  with  eft'usion. 
The  malady  is  insidious  and.  occurring  in  the  course  of  diseases  accom- 


l!l!^  DISEASES    OF    Till-:    llEAUT 

paiiifd  by  dyspiupa  causes" few  additional  .sitriis,  lieiiee  should  be  held 
ill  remenibrauce. 

The  normal  state  of  the  periearditun  durinfx  life  is  probably  like 
that  of  the  freshly-opened  peritoneum,  that  is,  humid  but  never  wet, 
hence  the  small  but  varying  amount  of  fluid  found  in  the  pericardial 
sac  after  death  is  probably  a  post-mortem  transudate. 

Hamnpi ricardium,  or  blood  in  the  pericardial  sac,  is  due  irenerally 
to  the  rupture  of  an  aneurysm  into  the  sac.  Aneurysms  of  the  first 
part  of  the  aorta  frequently  so  rupture  owing  to  the  attachment  of 
the  sac  being  about  two  inches  above  the  origin  of  the  great  vessels 
(Uray  I.  The  aneurysm  may  be  of  the  coronary  arteries  or  of  the 
heart  wall.  Rupture  or  wounds  of  the  heart  are  less  fretpient  but  pos- 
sible cau.ses.  Death  quickly  intervenes  in  all  these  eases  with  signs  of 
heart  failure  and  dyspnnea.  Percussion  shows  the  characteristic  dull 
ai'ea. 

PiKiimopfricardiiitn.  Gas  in  the  pericardial  sac  is  a  rare  condi- 
tion, hut  may  result  from  a  tuberculous  perforation  fi-om  the  lung 
or  the  a-sophagus.  or  perforation  through  the  diaphragm  from  cancer 
of  the  stomach.    It  has  followed  stab-wounds. 

Pericarditis  with  effusion  quickly  follows  and  the  adini.xture  of 
gas  and  Huid  gives  rise  to  a  movable  ai'ca  of  percussion  dullnes.s  asso- 
ciated with  tympany. 

On  auscultation  friction  souuds  are  heard  admixed  with  splash- 
ing, bubbling  and  churning  .sounds  which  are  remarkable  but  charac- 
teristic. The  heart  sounds  are  ob.scured  and.  if  heai-d.  ai-e  feeble  and 
distant.     Death  is  not  long  delayed. 

PHYSICAL  SIGNS  AND  SYjMPTOMS  OF  THE  VARIOUS  FORMS 
OF  VALVULAR  DISEASES— MITRAL  INSUFFICIENCY. 

This  is  the  most  frequent  form  of  valvular  disease,  yet  it  may 
exist  for  years  without  the  patient  being  aware  of  any  defect.  The 
first  manifestation  is  shortness  of  breath  on  going  iip  hill,  up-.stairs 
or  following  nnusual  exertion. 

As  explained  in  the  consideration  of  valvular  defects,  the  ineffec- 
tual closure  of  the  mitral  valve  allows  a  certain  amount  of  blood  to  be 
thrown  back  into  the  auricle  with  each  systole.  The  auricle  is  receiving 
at  the  same  time  the  blood  from  the  lungs.  The  two  currents  cause  an 
excessive  diastole,  which  inevitably  results  in  dilatation.  Owing  to 
the  excess  amount  of  work  neces.sary  to  expel  the  augmented  quantity 


DISEASES    OP    THE    HEART  199 

•of  blood,  auric-ulai'  hypertrophy  supervenes.  As  soon  as  this  condi- 
tion is  reached  each  auricular  systole  forces  an  increased  quantity  of 
blood  into  the  left  ventricle,  with  the  same  results  as  in  the  case  of  the 
auricle,  viz. — first  dilation,  then  hypertrophy  of  that  part. 

The  resultant  action  of  mitral  incompetency  upon  the  right  heart 
is  explained  as  follows : 

The  over-filled  left  auricle  impedes  the  emptying  of  the  pulmon- 
ary veins  into  the  cavity,  as  occurs  in  normal  hearts  during  diastole. 
This  venous  engorgement  and  the  consequent  increased  interpulmoiiavy 
pressure  prevents  the  free  expulsion  of  blood  from  the  riglit  vnitiicli' 
into  the  pulmonary  arteries,  and  dilation  of  that  chamber  results,  with 
subsequent  hypertrophy.  This  hypertrophy  causes  an  accentuation  of 
the  pulmonary  second  sound.  The  right  ventricular  dilation  results 
in  insufficiency  of  the  auricular-ventricular  valves  on  that  side  and 
finally  the  right  auricle  is  involved.  Venous  pulsation  in  the  neck 
indicates  its  occurrence,  and  betokens  venous  engorgement  elsewhere. 
The  stomach,  omentiim,  kidneys  and  liver  are  especially  involved. 
General  dropsy  supervenes ;  anasarca  is  accompanied  by  albuminiiria. 
The  association  of  liver  pulsations  with  tricuspid  disease  has  been 
pointed  out  and  occurs  here  as  a  late  lesion.  Owing  to  the  pulmonary 
engorgement  haemorrhage  is  apt  to  occur  and  is  not  confined  to  the  late 
stages  of  the  disease.  In  mitral  insufficiency  it  may  be  an  earlj" 
•symptom. 

Attacks  of  bronchitis  are  frequent,  due  to  the  same  predisposing 
cause. 

Symptoms.  The  disease  naturally  divides  itself  into  two  periods, 
•during  which  the  symptoms  and  physical  signs  vary  greatly.  These 
are  the  period  during  which  compensation  is  perfect,  and  the  period 
when  compensation  is  no  longer  maintained  and  during  which  the 
ever-increasing  venous  engorgement  originates  most  of  the  evils  of  the 
disease.  For  convenience  these  periods  will  be  referred  to  as  the  first 
and  second  stages  of  the  malady.  i 

Inspection.  The  area  of  the  visible  pulsation  is  increased  and 
difl'used,  especially  so  in  children.  The  apex  impact  is  in  the  nipple 
line  or  beyond  and  displaced  a  little  downward,  appearing  usually  in 
the  sixth  interspace.  In  children  the  praecordia  bulges.  The  face 
shows  a  certain  amount  of  venous  congestion  especially  over  the  cheek 
l)ones  where  the  veins  are  enlarged  and  thread-like.  The  lips  and  ears 
show  a  bUiish  tint ;  this  in  cases  of  long-standing,  even  with  compensa- 


2M 


OF    THK    IlKAKT 


tioii.     Clubbing  of  the  fini;ers  oceius  and  is  pioiiou'.u'i'd  in  children. 

In  the  first  stage  dyspncea  is  not  pronounced,  but  shortness  of 
breath  follows  unusual  exertion.  With  the  .second  stage  come  marked 
cyanosis  and  a  jaundice  tint,  and  dyspnoea  is  profound.  Irregularity 
of  the  heart's  action,  palpitation  and  diffusion  indicate  dilation.  Epi- 
gastric pulsation  occurs  in  the  second  stage,  when  the  right  heart  pai-- 
tieipates. 

Palpation.  First  stage.  Impulse  foi'cible  and  even  heaving. 
Second  stage.  Impulse  ditTused,  weak  and  irregular,  often  arj^hmic 
and  wa\y.  Thrill  is  rare.  If  present  it  is  felt  at  the  seat  of  the  apex 
heat  and  is  synchronous  with  the  first  sound.  The  pulse  is  regular  and 
full  during  compensation,  but  in  the  second  stage  becomes  small,  easily 
compressed  and  irregular.  When  once  this  irreuularity  sets  in  it  sel- 
dom ever  afterwards  disappears. 

Pi  i-riis-iUiii.     The  heart   boundaries  are  enlarged  latcralhj  inuc-h 


Fig.  45 — Pulse  iraciiig  in  a  case  of  mitr.->l  regurgitation  in  a  weli 
state   (Patton). 


conipeiisatcd 


more  than  roiicallij.  This  diagnostic  point  i.s  referi-cd  to  under  peri- 
carditis with  effusion.  When  the  right  ventricle  becomes  involved  this 
area  increases  on  both  sides  of  the  sternum.  No  other  form  of  valve 
disease  so  materially  ircrcases  the  transverse  diameter,  which  may 
extend  from  a  point  an  inch  beyond  the  right  sternal  margin  to  the  left 
anterior  axillary  line. 

Anscvltafio)!.  A  systolic  murmur  is  h.'aid  which  lias  its  greatest 
intensity  at  the  apex.  This  murmur,  as  already  .stated,  may  follow 
the  first  heart  sound  as  a  prolongation  thereof,  or  it  may  wholly 
replace  the  systolic  sound.  Its  character  is  generally  soft  and  blowing, 
but  may  be  musical.  Its  strength  or  loudness  depends  greatly  upon 
the  ventricular  contraction.  Change  in  this  respect  in  the  downward 
scale  portends  evil.  The  word  soft  used  in  this  connection  mu.st  not  be 
interpreted  to  mean  fffhh.  but  as  being  opposed  tn  hicrh-pitehed  ..cid 


DISEASES    OF    THE    HEAET 


201 


shrill.  This_  muminr  is  traBsmitted  directly  around  the  ribs  into  the 
axilla  and  can  usually  be  heard  as  far  as  the  angle  of  the  scapula. 
Sometimes  the  murmur  is  audible  in  the  recumbent  posture,  and  dis- 
appears when  the  patient  is  erect.  At  the  apex  as  a  rule  the  second 
heart  sound  heard  during  diastole,  is  loud  and  decisive.  It  is  due 
to  pulmonary  accentuation.  In  cases  of  great  hypertrophy  affecting 
both  sides  of  the  heart,  a  strong  systolic  blowing  sound  is  the  only 
murmur  heard.    In  mitral  regurgitation  the  disturbance  in  the  heart's 


Fig.  46 — Mitral  insufficiency,  showing  great  increase  in  the  transverse  area. 
Apex  beyond  the  anterior  axillary  line  in  7th  interspace.  Some  emphysema 
is  associated.  During  fourteen  years  equilibrium  has  been  well  maintained, 
until   within  three  months  of  present  time. 

rhythm  is  chiefly  in  the  direction  of  shortening  the  intervals  between 
the  systoles. 

The  above  describes  the  typical  state  of  affairs,  and  cases  are  fre- 
quently encountered  which  will  conform  with  exactness  to  the  picture. 
The  principal  variations  are  that  sometimes  the  murmur  is  best  heard 
along  the  left  border  of  the  sternum,  as  pointed  out  by  Naunyn,  or  at 


202 


DISKASES    ()!•'    THK    HEART 


the  base  of  the  heart  where  it  may  be  loudest,  and  may  be  audible  only 
in  that  situation,  as  mentioned  by  B.  Foster.  These  instances  are  rare. 
Sometimes  it  is  heard  ovei-  the  entire  cliest.  There  may  be  associated 
a  presystolic  mitral  murmur.  The  association  of  this  presystolic  with 
the  svstolie  mitral  iiiuriimr  is  the  unlv  nhstilulr  aiitc-moi-tem  evidence 


Fig.  47 — Dorsal   area  of  murmur,  mitral  rcgiirgitaticn.     Patient  shown  in  pho- 
tograph   (Fig.   46). 

which  we  pos.sess  of  positive  incompetency  of  the  mitral  valve,  since 
■dilatation  of  the  ring  with  relative  incompetency  and  sclerosis  will 
induce  an  identical  train  of  sequences.  Late  in  the  disease  tricuspid 
regurgitation  occurs  and  a  soft,  low  syi3toIic  murmur  in  the  tricuspid 
«nsiform  region  indicates  it.     This  lattei'  complication  is  also  evinced 


DISEASES    OF    THE    HEART 


203 


hx  a  marked  accentuation  of  the  pulmonary  second  sound  of  a  elaek- 
ing  character,  due  to  the  increased  tension  in  the  pulmonic  vessels. 

Diagnosis.    Four  cardinal  points  are  to  be  kept  in  mind: 

Apex  beat  displaced  to  the  left  and  downward. 

Transverse  area  of  dullness  much  increased. 

A  systolic  murmiu-  with  greatest  intensity  at  apex,  carried  back  to 
angle  of  scapula  with  dimini-shing  intensity'. 


Fig.  48 — Percussion  outline  and  area  over  which  is  heard  murmur  of  mitral  in- 
sufficiency in  patient  whose  photograph  is  shown   (Fig.  46). 

Accentuation  of  the  pulmonary  second  sound. 

The  relative  intensity  of  the  two  second  sounds  heard  at  the  base 
of  the  heart,  the  pubnonic  and  the  aortic,  vary  much  in  normal  indi- 
viduals, as  pointed  out  by  Vierordt.  In  children  the  pulmonic  sound 
is  almost  invariably  the  stronger  and  louder.  In  old  age  the  condition 
is  exactly  reversed.  In  adults  the  percentage  of  cases  of  pulmonic 
predominance  diminishes  with  each  decade. 


204 


DISEASES    OP    THE    HEART 


.MITRAL  STENOSIS. 

It  has  been  questioned  whether  mitral  stenosis  can  exist  without 
some  degree  of  regurgitation.    Balfour  maintains  that  it  cannot. 

The  mcdianism.  The  difficulty  of  expelling  its  blood  through  the 
narrowed  orifice  causes  the  left  auricle  to  dilate  and  to  hypertrophy. 
As  long  as  it  is  equal  to  the  extra  task  imposed  upon  it  compensation  i* 
maintained,  but  as  its  systole  is  prolonged  and  rendered  more  difficult, 
the  tension  in  the  pulmonai-y  veins  inci'eases  by  reason  of  the  impedi- 


Fig.  49 — Diagram  illustrating  mitral  insufficiency. 

ment  to  their  outflow,  and  the  right  ventricle  is  thus  forced  to  increase 
its  work  in  order  to  overcome  the  augmented  pulmonary  tension 
against  which  it  is  pumping.  Venous  congestion  of  the  systemic  veins 
indicates  that  the  right  heart  is  no  longer  capable  of  equalizing  the 
circulation.  Competency  is  not  maintained  for  the  protracted  periods 
often  observed  in  the  foregoing  variety  of  the  disease. 

The  heart  of  mitral  stenosis  is  in  marked  conti-ast  with  the 
incompetent  heart.  It  rarely  attains  any  great  size,  and  the  increase 
is  principalh-  in  the  left  auricle  and  the  right  ventricle,  which  latter 
forms  the  greater  pai-t  of  the  lower  anterior  cardiac  segment. 


DISEASES    OF    THE    HEART 


205 


Symptoms.  Cardiac  palpitation,  dyspnoea  and  stitch-like  pains 
about  the  apex  are  frequent  symptoms.  The  patients  are  prone  to 
be  anffimie  and  attacks  of  recurrent  endocarditis  are  apt  to  occur. 
They  are  indicated  by  febrile  attacks  and  marked  aggxavation  of  the 
circulatory  symptoms.  As  compensation  fails  venoits  engorgement 
of  the  lungs  results  and  induces  symptoms  which  differ  in  no  wise  from 
those  described  under  insufficiency. 

Inspection.  As  the  left  ventricle  is  not  enlarged  there  is  no 
bulging  in  the  apex  region,  but  in  children  there  may  be  a  prominence 


Fig.  50 — Diagram  illustrating  tricuspid  incompetency. 

of  the  ensiform  and  lower  sternal  regions,  or  of  the  left  lower  costal 
cartilages  caused  by  the  hj-pertrophy  of  the  right  ventricle.  The 
apex  beat  is  pushed  but  little  to  the  left,  seldom  beyond  the  nipple 
line.  Often  it  is  not  weU-defined,  but  is  replaced  by  a  diffused  pidsa- 
tion  to  the  right  of  the  apex  beat  in  the  region  of  the  fifth  and  sixth 
left  costal  cartilages,  which  is  due  to  the  impact  of  the  hypertrophied 
right  ventricle,  which,  as  already  explained,  lifts  the  apex  from  the 
chest  wall.  The  pulsation  seen  in  the  third  and  foiu-th  left  inter- 
spaces in  persons  with  thin  chest  walls  has  been  generally  ascribed  to 
the  enlarged  left  auricle.     This  is  very  probably  erroneous,  the  pul- 


20(j  DISEASES    01"    TUK    IlKAIiT 

satioii  beiii'4'  ill  i-oalilv  due  to  thr  inipulsi'  ol'  llir  rmnis  arteriosus  of. 
the  right  venlrielc 

Engorgeineut  ami  |iulsati(iii  nf  tlic  jiii;ulai-s  iiuliratc  failiin;  of  the 
right  ventricle  to  maintain  equilibriimi. 

Palpation.  The  heart  impact  i.s  difVused  and  is  Irlt  most  r()i-eibl\ 
in  the  region  to  the  right  of  the  lower  sternum.  Epigastric  pulsation 
is  not  rare.  Palpation  furnishes  the  most  definite,  significant  and 
tru.stworthy  sign  of  mitral  stenosis.  It  is  the  shaip  tlnill  which  is 
felt  over  a  very  limited  area  whose  center  is  the  rouilli  interspace 
just  within  the  nipple  line.  It  may  extend  as  high  as  the  thii-d  or  as 
low  as  the  fifth.  It  is  rough  and  rasping  in  quality,  begins  during 
diastole  as  a  purring  fremitus,  gathers  force  with  the  auricular  systole, 
which  is  its  true  cause,  and  terminates  as  an  abrupt  shock  with  the 
beginning  of  ventricular  systole.     The  sign  is  pathognomonic.     Wben 


l-'iy.   tI — I'ulsf  tracini;  in  ;i  case  •<!  mitral  stenosis   (Patton). 

not  appreciable  during  repose  it  may  be  elicited  by  slight  exertion. 
Anders  states  that  ttirning  the  patient  upon  the  left  side  and  elevating 
the  arms  accomplishes  the  same  result.  When  compensation  fails  tlie 
thrill  disappears  and  the  lesion  may  be  overlooked.  With  ret^stablish- 
ment  of  equilibrium  the  mnrmnr  rttnrns. 

Pnrusxion.  The  increase  in  percussion  dullness  is  principally  to 
the  right  and  may  extend  as  far  as  two  inches  beyond  the  sternum. 
On  the  left  it  seldom  extends  beyond  the  nipple-line  and  is  due  for  the 
most  part  to  increase  in  the  size  of  the  right  ventricle.  The  vertical 
boundaries  are  also  increased  and  the  base-line  moves  up  to  the  second 
interspace. 

AuscuUalion.  A  rough,  vibrating  thrill  or  ptiri-  is  heaifl  in  the 
apex  circle  or  a  little  within  and  above  the  apex  point.  In  time  it  is 
diastolic  and  may  occupy  the  entire  diastolic  period,  or  it  may  be 
present  only  during  the  latter  part  of  diastole,  that  is  to  say  during 
auricular  systole.    In  either  ca.se  it  terminates  abrtiptly  with  the  von- 


DISEASES    OF    THE    HEAHT 


207 


triciilar  shock.  Its  time  is  best  ascertained  by  combined  palpation 
and  auscultation.  "When  it  fills  the  entire  diastolic  period  the  two 
parts  of  the  murmur  may  show  differences  in  quality  sufficient  to 
divide  it  (Gairdner). 

In  the  second  left  interspace  the  second  soiind  is  unmistakably 


Fig.  52 — Enlargement  of  heart  in  mitral  lesions   (Patton). 

accentuated  and  often  reduplicated.     Sansom  says  this  reduplication 
is  present  in  one-third  of  the  cases. 

The  first  heart  sound  heard  in  the  apex  region  is  sharp,  clear  and 
short.  Whether  this  sound  arises  from  accentuation  of  the  tri  cuspid- 
closure  or  whether  due  to  the  sharp  muscle  contraction  of  abbreviated 


208 


DISEASES    OF    THE    HEART 


systole,  as  held  by  Broadlifiil,  remains  an  Dpcii  (|iu'sliiin.  lOvi'u  wheu 
compensation  has  failed,  the  thrill  disappeared  and  the  eardiae  rhythm 
has  become  galloping,  this  sonnd  retains  its  clearness. 

The  regularity  of  the  heart's  action  is  aft'ected  as  shown  by  the 
cardiograph.  The  diastolic  intervals  vary  greatly  in  length  and  the 
intervals  between  the  systoles  are  prolonged. 

The  mnrmnr  of  mitral  incompetency  may  lie  associated  with  the 
presystolic  niurmur,  and  later  with  that  of  trieiisjiid  ini'onipeteucy. 
Mitral  stenosis  is  generally  a  primary  affection. 


F'g-  S3 — Mitral  insufficiency  with  large  area  of  hypertrophy.  Patient  is  laborer 
with  powerful  physique.  Murmur  hmited  to  small  area  on  back  to  which 
it  is  directly  transmitted.     See  Fig.  54. 

The  Pulse.  The  radial  pulse  is  small  in  volume,  irregular  and 
easily  compressed,  and  as  the  power  of  the  right  ventricle  diminishes 
these  characteristics  increase.  So  long  as  equilibrium  is  perfect,  the 
pulse  is  small,  and  may  be  quite  regular. 

The  terminal  symptoms  are  the  same  as  those  of  incompetency, 
except  that  dropsy  is  less  apt  to  occur.  Pressure  of  the  enlarged 
auricle  upon  the  left  recurrent  laryngeal  nerve,  causing  paralysis  of 
the  vocal  cords,  is  mentioned  by  Herrick  and  by  O.sler. 


DISEASES    OF    THE    HEART 


209 


MITRAL  INSUPPICIENCY  AND  STENOSIS. 
The  combined  lesion  is  more  common  than  a  pure  stenosis,  as  a 
study  of  the  valve  conditions  would  lead  one  to  suppose.  The  physical 
signs  of  the  two  conditions  are  then  combined.  The  hypertrophy,  the 
thrill,  the  accentuation  of  the  second  sound,  and  a  double  murmur  with 
seat  of  intensity  in  the  mitral  area,  summarize  the  phenomena.     The 


Fig.  54 — Small  area  on  the  back  to  which  the  mitral  murmur  (Fig.  53)  was  di- 
rectly transmitted.  It  was  very  faint  in  the  axilla.  The  figures  are  on  the 
tips  of  the  vertebral  spines. 

pulse  in  this  case  is  small,  irregular  and  frequent.     The  seciuelffi  are 
those  of  incompetency. 

AORTIC  INCOMPETENCY. 

Incompetency  of  the  aortic  valve  is  the  best-defined  and  the  most 
easily  recognized  of  valvular  lesions. 

The  mechanism  of  the  disease  is  as  follows : 


210  DISEASES    OP    THE    HEAKT 

The  insuffifient  semilunar  valves  permit  a  portion  of  the  blood 
pumped  into  the  aorta  to  regurgitate  into  the  left  ventricle.  The 
regurgitation  occurring  at  the  time  when  that  chamber  is  tilling  from 
its  auricle,  the  effect  of  the  double  supply  of  blood,  is  to  cause  dilata- 
tion of  the  ventricle,  which  is  ultimately  followed  by  its  hypertrophy. 
As  the  two  processes  act  continuously  the  necessity  for  ever-increasing 


F'g-    55 — Mitral    systolic   murmur — scat   of   greatest   intensity    ;ind    direction    of 
propagation  with  diminishing  intensity. 

hypertrophy  is  manifest.  The  muscular  endowment  of  the  ventricle 
walls  allows  it  to  attain  a  degree  of  hypertrophy  which  surpasses  that 
possible  in  the  case  of  any  other  portion  of  the  heart.  Cases  have  been 
recorded  in  which  a  heart  weight  of  forty-eight  ounces  was  reached. 
As  long  as  the  two  processes  go  on  harmoniously  equilibrium  is  main- 
tained :  no  evil  results  follow,  and  the  discover}-  of  the  condition  may 
be  accidental. 


PLATE  XIV. 


Aortic  Diastolic  Murmur,  seat  of  greatest  intensity  and  direction  of 
propagation.     AP.     Position  of  Apex. 


DISEASES    OF    THE    HE.VET 


211 


The  difficulty  experienced  by  the  left  auricle  in  ridding  itself 
of  its  contents,  owing  to  the  raised  pressure  in  the  ventricular  chamber, 
causes  it  to  dilate  and  then  to  hypertrophy,  and  to  increase  the  length 
of  its  systole.  The  raised  pressure  within  the  veins  of  the  lungs  thus; 
produced  must  be  counter-balanced  by  increased  pump-work  on  tlie^ 
part  of  the  right  ventricle,  hence  inevitably,  after  a  longer  or  shorter' 
time,  the  right  heart  shows  secondary  dilatation  and  hypertrophy,  in' 
which  the  dilatation  is  finally  paramount.  The  student  will  under- 
.stand  that  pathologic  results  are  not  always  easily  distinguished  from 


Fig.  56 — Pulse  of  aortic  regurgitation.  Ape.x  acute.  The  height  to  which  the 
lever  rises  is  materialiy  influenced  by  the  amount  of  pressure  made  upon 
the  button.  D  Aortic  valve  closure.  Dicrotic  notch  marked.  Predicrotic 
notch   absent. 

causes,  and  that  the  mechanism  and  order  of  sequence  above  given  may 
be  diversified  on  quite  as  reasonable  grounds  as  those  here  assumed.. 

PHYSICAL  SIGNS. 

Inspection.  The  apex  is  seen  in  the  sixth  or  seventh  interspace; 
as  far  to  the  left  as  the  anterior  axillary  line.  The  impulse  is  dif- 
fused and  undulatory  during  the  dilatation  period,  wide  and  forcible 
during  hypertrophy.  Bulging  is  seen  in  children;  the  entire  prae- 
cordia  is  raised.  Occasionally  during  systole  there  is  a  depression  of 
the  prfficordia  between  the  sternum  and  the  nipple,  due  to  atmospheric 
pressure. 

Palpation.  The  character  of  the  impact  is  wavy  and  undulatory, 
or  strong  and  heaving. 

Percussion.  The  area  of  dullness  is  enormous  in  advanced  cases,, 
attaining  here  its  greatest  limits.  The  transverse  area  extends  to  the' 
left  beyond  the  anterior  axillary  line  and  downward  as  far  as  the- 
seventh  interspace. 

Auscultation.  A  murmur  is  heard  with  maximum  intensity  in 
the  second  right  interspace  (aortic  cartilage).    It  is  transmitted  down- 


212  DISKASIOS    OF     THE    IlEAHT 

ward  mIiiii^  Imtli  lionlcis  of  thi'  stci'imm  lowards  the  ai)OX  ami  llic 
nisit'iu'iii  i-ai'f ilniii'. 

SiiiL-i.'  il  is  pindiii-cd  liy  Ihe  n'thix  of  l)l(>cid  duriiiu'  the  tilliTig  of 
the  ventricle  the  iiiiiriiuir  Dt-L-iii-s  diii'iiijj;  diastole,  and  therefore  re- 
places 1h(  second  sound  of  the  Imirf.  or  is  intermingled  therewith 
in  eases  where  the  leaflets  are  still  capable  of  closure.  In  these  cases 
both  the  nuu-niur  and  the  valve-sound  may  be  distinct.  The  quality  of 
the  nnuiiuir  varies  gieatly.  Oftenest  it  is  a  long,  soft,  souffle,  but 
may  he  harsii  and  r;:sping.  Osier  says  it  is  the  most  trust\vortli>-  of  all 
cardiac  murnnns.  Wr  think  il  is  not  more  indicative  tluin  llir  \n-r- 
systolie  mitral  thrill. 

Associated  Miiriniirs.  In  many  ca.ses  of  aortic  incompetency  the 
arch  of  the  aorta  has  become  roughened  by  atheromatous  deposits. 
This  roughening  gives  rise  to  a  systolic  murnuir  which  is  present  in 
about  one-third  of  all  eases.  The  roughened  semilunar  valve  segments 
also  are  wont  to  originate  a  nmnmir  l>y  the  passage  of  ont-bound  blood 
over  their  surfaces.  The  presenc^'  of  these  nmrnnirs  is  often  infiM'- 
preted  to  mean  aortic  stenosis,  although  only  a  small  proportion  nf  thr 
cases  show  any  real  nan-owing  of  the  aortic  orifice.  Both  sounds  are 
systolic  and  may  be  lieard  beyond  the  aortic  area.  In  most  cases  of 
aortic  incompetency  the  ventricular  dilatation  and  hypertrophy  en- 
large the  mitral  ring,  causing  relative  insufficiency  of  its  valves,  giving 
rise  to  the  systolic  murmur  of  mitral  incompetency.  That  this  mur- 
nuir arises  at  the  mitral  valve  and  is  not  a  conducted  murmur  is  shown 
by  the  fact  that  its  quality  is  often  materially  different  from  the 
systolic  murmtu-  just  described  as  arising  from  the  aortic  valve.  This 
aortic  murmur  is  rough,  high-pitched:  the  mitral  .soft  and  blowing. 

Flint  Murmur.  Yet  another  murnuir  is  heard  in  the  mitral  or 
apical  area,  but  is  less  common  than  the  systolic  bruit.  This  second 
murmur  is  known  fi'om  its  describer  as  the  Flint  murmur.  Its  quality 
is  I'umbling,  its  area  limited  and  its  time  presystolic  or  diastolic. 
Whether  it  is  due  to  the  inflowing  blood  from  the  left  auricle,  or  to 
the  reflux  current  from  the  aorta  producing  vibration  of  the  mitral 
leaflets,  is  uncertain.  Flint  believed  that  the  dilatation  of  the  ven- 
tricle prevented  the  mitral  leaflets  from  folding  completely  backwards 
against  the  chamber  walls  and,  thus  acting  as  an  impediment,  produced 
the   bruit. 

The  pulse  is  described  elsewhere.  The  delayed  radial  pulse  which 
follows  the  apex  beat  after  a  distinct  intei'val  is  characteristic,  and  the 


DISEASES    OF    THE    HEART 


•213 


length  of  the  interval  increases  with  the  increase  of  the  incompetency. 
In  the  carotids,  especially  the  right,  the  systolic  niui-mui-  may  be  qnite 
as  apparent  as  at  the  cartilage,  and  the  second  aortic  sound  may  be 


Uv^-^l 


Fig.  57 — Enlargement  of  the  heart  in  aortic  regurgitation  (Patton).  A  Area 
of  greatest  intensity  of  murmur,  somewhat  depressed.  B  Direction  of 
transmission  of  murmur. 

perfectly  distinct  here,  even  when  absent  over  the  valve.  Broadbent 
considers  this  a  favorable  sign,  indicating  that  the  amount  of  regurgi- 
tation is  smaU. 


214  DISEASES    OF    THE    HEART 

Other  Symptoms.  Cardial-  palpitation,  distress  and  I'aiiiluess  ou 
sudden  exertion  or  rising,  are  very  early  features,  due  to  arterial 
aiueniia.  Pain  and  even  angina  are  frequent.  Headaches,  dizziness 
and  attacks  of  synco[)e  from  disturbed  cerebral  eireulatiou  are  not 
unconnnon  and  likewise  may  be  early  manifestations. 

Nocturnal  dyspna-a  and  redema  of  the  ankles  and  under  the  eyes 
indicate  failing  compensation.  The  patient  sleeps  at  first  with  the 
head  elevated,  then  in  a  chair,  lastly  at  a  table.  The  sleep  is  fitful 
and  disturbed  by  a  sense  of  impending  suffocation.  General  dropsy  is 
not  a  terminal  complication  unk\ss  mitral  disease  is  associated.  Endo- 
carditis, emboli,  paralysis  and  ha'maturia  may  each  play  its  part. 

It  is  in  aortic  incompetency  that  sudden  death  frequently  occurs, 
due  in  many  cases  to  sudden  over-distention  of  the  left  ventricle.  In 
others,  the  ease  progresses  through  the  stages  of  venous  congestion  and 
pulmonary  engorgement  to  general  dissolution. 

AORTIC  STENOSIS. 

Pure  aortic  stenosis  is  the  least  frequent  of  the  valvular  affections 
of  the  left  side  of  the  heart.  In  almost  every  case  of  stenosis  there  is 
some  incompetency.  The  majority  of  the  cases  are  found  in  old  men, 
associated  with  extensive  atheromatous  changes  of  the  arteries,  and  the 
older  the  .subject  the  greater  the  likelihood  of  there  being  calcareous 
deposits  within  the  aortic  i-ing.  Uncombined  aortic  .stenosis  is  the 
least  dangerous  of  the  various  forms  of  valvular  disease. 

The  first  effect  of  the  stenosis  is  hypertrophy  of  the  left  ventricle. 
Since  there  is  no  over-filling  or  backward  flow  in  this  lesion,  simply  a 
demand  for  increased  power  of  propulsion,  the  hypertrophy  comes 
about  with  little  or  no  dilatation.  The  cavity  walls  thicken  enor- 
mously without  enlargement  of  the  chamber.  As  long  as  compensa- 
tion is  perfect  the  change  is  confined  to  the  left  ventricle.  With  failure 
of  compensation  dilatation  occurs,  then  its  auricle  suffei's  and  in\dlves 
the  right  heart  in  the  same  order  as  was  involved  the  left.  Willi  the 
left  ventricular  dilatation  comes  enlargement  of  the  mitral  ring,  and 
relative  incompetencj'  of  that  valve. 

Inspection.  Even  when  considerable  hypertrophy  is  present  the 
apex  impulse  may  be  invisible,  or  if  visible,  may  be  feeble.  More 
often,  however,  it  is  slow,  forceful  and  heaving.  It  is  displaced  down- 
ward and  outward  into  the  sixth  or  seventh  interspace. 

In  old  men  considerable  emphysema  of  the  lungs  is  present  and 


DISEASES    OF    THE    HEAET 


215 


serves  to  obscure  the  impact  as  well  as  to  diminish  the  area  of  dullness. 
Palpation.  The  impulse  may  be  impalpable  and  feeble,  or  force- 
ful owing  to  causes  given.  .  The  chief  diagnostic  symptom  is  the  pres- 
ence of  a  well-marked  thrill  felt  over  the  base  of  the  heart,  and  cen- 
tering over  the  aortic  region.  It  occurs  with  systole  and  may  be  of 
great  intensity.  In  some  eases  it  may  be  felt  with  diminished  inten- 
sity over  the  apes.     (Anders.) 


Fig.    58 — Mitral    presystolic   murmur,    area   and    direction. 

Percussion.  The  area  of  dullness  is  increased  transversely,  but 
never  to  the  extent  foiind  in  aortic  insuiSeiency.  Usually  the  area 
as  marked  out  by  percussion  falls  much  within  the  true  cardiac 
boundaries,  owing  to  the  masking  of  the  dullness  by  the  emphysema. 

Auscultation.  A  harsh,  loud,  prolonged  murm\u-  is  heard,  sj-n- 
chronous  with  each  systole.  Its  point  of  greatest  intensity  is  either  the 
second  right  or  the  second  left  interspace  close  to  the  sternum.  The 
second  sound" is  obscured  or  more  generally  absent,  since  the  lesion  so 


216 


niSEASES    OP    THE    HEART 


thickens  and  stil'lVns  tlu'  valve  leaflets  as  to  pn'veiit  tlieii-  elcisure.  As 
the  ventricle  loses  power  with  dilatalioii,  Uic  niuriiiur  softens  in  tone 
and  late  in  the  disease  may  disappear. 

Associated  leakage  and  roughening  ai'e  manifested  by  the  some- 
times present  diastolic  murmur  causing  a  see-saw  sound.  Although 
the  conditions  necessary  for  the  i)roduction  of  this  see-saw  murmiu* 
are  very  frequently  present,  yet  it  is  so  often  masked  by  the  systolic 
thrill  that  it  is  inaudible.  The  systolic  thrill  is  propagated  into  the 
gi-eat  vessels.  When  mitral  incompetency  supervenes,  it  is  indicated 
by  a  nuu-mur,  also  sj'stolie,  sometimes  musical,  which  is  heard  at  the 
apex.    Tricuspid  involvement  manifests  itself  in  the  usual  way. 

The  pulse  is  the  pulsus  tardus ;  small,  well-maintained  in  tension 
but  slower  than  normal.  The  accompanying  tracing  shows  its 
character. 


Curve  of  mitral  stenosis. 
Fig.  59. 

Diagnosis.     These  findings  point  to  aortic  .stenosis : — 

A  roiigh,  loud,  musical  systolic  nuirmur  of  maximum  intensity  at 
the  aortic  cartilage. 

A  thrill  felt  at  the  base. 

Signs  of  hypertrophy  of  the  left  vciilricle. 

The  pulsus  tardus. 

The  mistakes  are  due  to  auicmic  nuiniiurs  whicli  arc  nuich  softer, 
more  apt  to  be  found  in  the  young,  often  intermittent,  uiuiccompanied 
by  thrill,  and  disappear  laidfr  Ind/iiniil.  In  aii:cniias.  the  second 
aortic  sound  is  accentuated. 

Bright's  disea.se  produces  cardiac  enlargement  with  which  ai'terio- 
.selerosis  is  commonly  associated,  but  the  urinarj-  sym|)toms  point  to 
the  disease,  and  in  the  aortic  calcification  of  this  condition  the  second 
sound  is  not  absent,  as  it  is  in  stenosis. 

Other  Symptoms.  Cerebral  anremia  during  the  failing  stage 
brings  on  attacks  of  syncope  or  dizziness,  often  of  the  most  distressing: 


PLATE  XV. 


Aortic  Stenosis.     Seat  of  Greatest  Intensity.   T,  Thrill.     Tliis  Murmur 
may  be  Audible  all  over  the  Chest  and  in  the  Great  Vessels. 


DISEASES    OP    THE    HEAET 


217 


character.  In  a  case  under  observation  the  dizziness  is  centripetal, 
that  is  the  patient  always  describes  an  ambulatory  circle  to  the  right 
and  falls  towards  its  center. 

General  oedema  and  dropsy  are  rare.  Gildema  of  the  feet  occurs. 
The  other  sjinptoms  are  due  to  associated  lesions. 

AOKTIC  STENOSIS  AND  INSUFFICIENCY. 

As  stated  by  Broadbent,  there  are  few  if  any  eases  of  aortic 
stenosis  without  some  insuiSciency  and  the  double  aortic  lesion  is  by 
many  writers  ranked  next  in  frequency  to  mitral  incompetency,  hence 
a  double  aortic  lesion  is  more  frequent  than  a  single  one.  Hyper- 
trophy of  the  left  ventricle  reaches  the  same  mammoth  proportions 
as  in  the  single  lesion  and  the  vascular  phenomena  are  little  modified. 


Mitral    disease.    Compensation   fairly  well   maintained.      Inequality  of    force    of 
successive  beats  shown — insufficiency  slight. 


Combined  aortic  and  mitral  disease,  hypertrophy  marked,  pulsus  alternans. 
Fig.  60. 

The  double  aortic  lesion  is  evinced  by  a  double  murmur,  systolic 
and  diastolic,  best  heard  over  the  base,  on  both  sides  of  the  sternum, 
and  named,  from  its  striking  similarity  to  the  sound  of  that  vessel 
when  afar  off,  the  steam-tug  murmm-. 

The  combination  of  aortic  stenosis  and  mitral  insufficiency  gives 
rise  to  sjTiehronous  systolic  murmurs,  one  centering  in  the  apical 
region,  conducted  across  the  axillary  space  toward  the  scapular  angle, 
the  other  best  heard  at  the  aortic  cartilage,  conducted  into  the  vessels 
of  the  neck. 

TRICUSPID  REGURGITATION. 

The  causes  may  be  grouped  under  three  heads : 

I.     Inflammatory.    Acute  or  chronic  endocarditis  with  resulting 


218  DISEASES    OF    THE    HEART 

deformity — occasional.  Fcetal  endocarditis  is  more  prone  to  attack  the 
right  than  the  left  side.  According  to  Rauchfuss  endocarditis  is  more 
common  on  the  right  side  of  the  foetal  heai-t  only  because  the  valves 
are  there  most  often  the  seat  of  developmental  errors. 

II.  Vahnilar  lesions  of  the  left  heart  producing  relative  insuffi- 
ciency by  the  ensuing  obstruction  to  the  pulmonary  circulation — more 
common. 

III.  Obstruction  to  the  pulmonary  circulation  occasioned  by 
cirrhosis,  fibroid  phthisis,  emphysema  and  chronic  bronchitis — most 
frequent. 

The  ventricle  first  hypertrophies  and  then  dilates.  The  blood  is 
projected  into  the  right  auricle  and  thence  into  the  veins  of  the  neck. 
The  strength  of  the  venous  pulsation  indicates  the  foi'ce  of  the  i-egurgi- 
tation.  When  the  dilatation  and  insufficiency  are  great  the  pulsation 
is  strong.  The  right  external  jugular  best  displays  the  throb,  but  the 
subclavian  and  axillary  veins  may  also  show  it.  It  is  best  seen  when 
the  patient  is  semi-recumbent.  It  is  greatly  intensified  by  coughing 
and  is  an  important  physical  sign. 

Inspection.  In  addition  to  the  signs  of  overloaded  veins  and 
venous  pulsation  an  impulse  is  seen  in  the  epigastric  region,  or  on  one 
or  other  side  of  the  ensiform  cartilage,  which  is  caused  by  the  hyper- 
trophied  ventricle.  Holding  the  breath,  coughing  or  blowing  increase 
its  force  as  well  as  that  of  the  venous  throb.  As  already  explained, 
hypertrophy  of  the  right  ventricle  lifts  the  left  ventricle  away  from 
the  chest  wall,  so  that  the  apex  beat  on  the  left  is  invisible.  The  pul- 
sating liver  may  be  visible. 

Palpation.  The  above-mentioned  signs  are  confirmed.  Liver  pul- 
sation is  less  often  seen  than  felt. 

Percussion.  The  area  of  dullness  is  increased  to  the  right  of  the 
■sternum.    If  the  disease  is  secondarj^  the  increase  is  also  to  the  left. 

Auscultation.  A  systolic  murmur  having  its  greatest  intensity  in 
the  lower  sternal  region  is  heard.  The  murmur  is  soft,  blowing  and 
of  low  pitch,  and  while  less  widely  transmitted  than  the  corresponding 
mitral  murnuir,  is  often  heard  in  the  right  axilla.  Even  when  asso- 
ciated with  a  mitral  systolic  murmur  the  softer  quality  aud  lower  pitch 
of  the  tricuspid  bruit  enables  one  to  separate  the  two  sounds.  The 
■co-existence  of  venous  pulsation  with  this  bruit  may  be  taken  as  posi- 
tive indications  of  the  lesion. 

False  murmurs  seldom  attach  themselves  to  the  tricuspid  valve 


DISEASES    OF    THE    HEART  219 

aad  physiologic  venous  pulsation  is  not  systolic.  It  corresponds  with 
auricular  and  not  ventricular  contraction. 

Diagnosis.  The  diagnosis  of  tricuspid  insufficiency  presents  no 
■difficulties,  and  with  these  three  points  in  mind  a  positive  opinion  may 
be  given. 

Increased  area  of  dullness  to  the  right  of  sternum. 

Systolic  mm-miu-  centering  at  xiphoid. 

Venous  pulsation  in  external  jugulars. 

The  tricuspid  murmur  which  develops  secondarily  to  a  mitral 
systolic  murmur,  owing  to  its  softer  quality  and  lower  pitch,  may  be 
inaudible.  In  that  ease  the  venous  pulsation  may  be  taken  to  indicate 
the  lesion,  especially  if  hepatic  pulsation  co-exists.  Asystole  sometimes 
•develops  and  portends  evil. 

Other  Symptoms.  The  sjTnptoms  are  those  of  the  allied  heart 
lesions  or  of  the  co-existent  bronchitis,  emphysema  and  pulmonary 
-cirrhosis.  General  venous  engorgement  and  universal  anasarca  pre- 
vail. The  kidney  and  liver  engorgement  are  followed  by  a  complex 
symptom  train. 

TRICUSPID  STENOSIS. 

The  disease  seldom  exists  as  an  isolated  affection.  Congenital 
-cases  die  young.  Women  are  afflicted  four  times  as  often  as  men.  It 
is  secondary  to  lesions  of  the  left  heart.  The  mechanism  is  exactly  like 
that  of  mitral  stenosis  with  which  lesion  it  is  oftenest  associated. 

The  physical  signs  are  not  always  well-defiued. 

Inspectio-n.  Cyanosis,  especially  of  the  face  and  lips,  is  generally 
present. 

Palpation.     Even  when  present  the  thrill  can  rarely  be  felt. 

Percussion.  Slight  change  in  cardiac  area,  a  little  increase  to  the 
right  of  the  sterniim. 

Auscultation.  Thrill  may  be  present  and  is  presystolic.  A  pre- 
systolic murmur  is  often  to  be  made  out  in  the  costal  angle  at  the  right 
of  the  ensiform  cartilage,  sometimes  in  the  fourth  or  sixth  right  inter- 
spaces. Either  the  murmur  is  often  absent  or  the  miirmur  of  the 
-associated  mitral  stenosis,  of  which  it  forms  one  of  the  most  serious 
•complications,  so  obscures  it  that  it  is  indiscernible.  General  anasarca, 
•extreme  and  obstinate,  is  an  end  sjonptom. 

Diagnosis  is  difficult  owing  to  the  masMna'  of  the  bruit.     It  is 


220  DISEASES    OK    THE    HEART 

seldom  made.     The  preseiu-e  of  tlie  tliiill  is  i-mivinciny.     Venous  reple- 
tion iiud  tli-opsy  suggest  it. 

PULMONARY  VAIA'E  DISKASKS. 
These  lesions  are  rare.  Under  the  caption  False  .Muiiuurs  are 
mentioned  some  of  the  conditions  which  are  mistaken  for  pulmonary 
valvular  diseases.  Care  must  he  taken  not  to  mistake  the  transmitted 
mitral  murnuir  mentioned  under  that  disease,  which  occasionally  cen- 
ters around  the  root  of  the  pulmonary  artery,  for  disease  of  this  valve. 
Puhnonary  insufficicncij  is  the  i-arest  ol'  all  valvular  defects.  It 
is  generally  congenital. 

Inspection.  Constant  cyanosis,  great  venous  congestion  and 
dyspnoea  are  marked  .symptoms.  Jugular  pulsation  is  mentioned  by 
Thompson. 

Palpation — negative. 

Percussioii.  Hypertrophy  of  the  right  heart,  of  moderate  degree. 
A-usculfation.  The  lesion  should  be  evidenced  by  a  diastolic  mur- 
mur of  maximum  intensity  in  the  second  left  intercostal  space.  The 
corresponding  murmur  of  aortic  insufficiency  theorcticaly  centers  on 
the  opposite  side  of  the  sternum,  but  in  fact  the  differential  inn  by 
position  is  impracticable  and  in  any  case  is  extremely  diflienlt.  The 
rarity  of  the  one  contrasted  with  the  frerpu'ne>-  of  the  other  alfords. 
ample  grounds  for  error  if  not  for  excuse. 

The  strongest  differential  point  is  that  the  vaseuhir  phenomena 
aceojnpanying  aortic  insufficiency,  are  absent  in  the  pulmonary  disease. 
Pulmonary  stenosis,  also  congenital,  is  caused  by  union  of  the 
valve  segments.  Cases  are  occasionally  encountered  in  which  vegeta- 
tions are  the  cause  of  both  insufficiency  and  stenosis  (Suattuck).  The 
congenital  eases  are  associated  with  compensatory  lesions  of  the  for- 
amen ovale  or  ductus  Botalli,  or  imperfect  ventricular  seiitinii  due 
to  arrest  of  development. 
rnspccfion :     Negative. 

Palpalioti.     There  may  be  a  thrill  in  the  second  left  intei-costal 
space. 

Percussion.     Slight  enlargement  of  i-ight  heart. 
Auscultatiott.     Thei'e  should  be  a  systolic  murnnir  with  point  of 
greatest  intensity  to  the  left  of  the  sternum  in  the  second  interspace. 
This  murnuu-  is  not  transmitted  into  the  vessels  of  the  neck.    The 


PLATE  XVI. 

Mitral  and  Tricuspid  Systolic  Murmurs.      The  "Hour-Glass"  Murmur. 


DISEASES    OF    THE    HE^VKT  221 

piilmonarT  second  soimd  wovUd  be  absent  or  replaced  by  a  diastolic 
miu-mur.  since  incompetency  is  necessarily  associated. 

The  differentiation  from  the  mui-mnr  of  aortic  stenosis  presents 
difficiilties.  The  left-sided  hypertrophy  is  absent  in  the  pulmonary 
form. 

ORDER  OF  FREQUENX'Y  OF  THE  SIMPLE  AND  THE  COM- 
BINED CARDIAC  LESIONS. 

Statistics  differ  materially  as  to  the  order  of  frequency  of  both 
simple  and  combined  lesions.  The  following  order  is  as  nearly  correct 
as  available  figures  permit: 

1.  ilitral  incompetency. 

2.  Aortic  incompetency. 

3.  ^Mitral  stenosis. 
i.     Aortic  stenosis. 

5.     Tricuspid  stenosis. 

The  claim  of  mitral  incompetency  to  supremacy  is  undisputed. 
Aortic  incompetency  and  mitral  stenosis  are  practically  equal  in  fre- 
quency, and  the  same  may  be  said  of  the  two  forms  of  triciLspid  disease. 
Of  double  murmurs,  heard  at  the  same  orifice,  the  mitral  lesions  are 
more  frequent  than  the  double  aortic  murmurs. 

The  combined  lesions  occur  in  the  following  order  of  frequency : 

The  mitral  and  aortic  segments  are  most  often  affected  together. 

Next  in  frequency  is  the  combination  of  mitral  and  tricuspid 
lesions:  then  of  aortic,  mitral  and  tricuspid. 

In  children  the  most  common  combination  is  mitral  insufficiency 
with  aortic  insufficiency.  In  adults  mitral  insufficiency  with  aortic 
stenosis  and  insufficiency  is  perhaps  the  oftenest  found  combination. 

The  following  order  is  taken  from  the  stati.sties  of  F.  J.  Smith: 

1.  Aortic  incompetency  and  stenosis:    Mitral  incompetency. 

2.  Aortic  stenosis  and  mitral  incompetency. 
Aortic  incompetency  and  mitral  incompetency. 
Equal. 

4.  Aortic  incompetency  and  stenosis:  mitral  stenosis  and  in- 
competency. 

5.  Mitral  incompetency  and  tricuspid  incompetency. 

6.  Aortic  incompetency  and  stenosis :  mitral  incompetency,  tri- 
cuspid incompetency. 


222  DISEASES    OF    THE    HEART 

CONGENITAL  CARDIAC  DEFECTS. 

Two  causes  are  recognized:  arrested  developnieiit  and  fojtal 
endocarditis. 

Acardia,  double  heart,  de.\tro-cai-dia  and  malposition  of  the  heart 
are  pathologic  curiosities.  Defective  auricular  or  ventricular  septum 
is  more  common.  When  the  opening  is  very  small  or  slit-lilce  little 
harm  seems  to  result.  Patent  foramen  ovale,  imperfect  septum  and 
persistence  of  the  ductus  arteriosus  Botalli  each  exists  alone  or  com- 
bined with  stenosis  of  the  puhiionary  valve.  Patent  foramen  ovale  is 
sometimes  found  post-mortem  when  tlie  defect  has  been  unsuspected. 
Peacock  states  that  the  most  frequent  conditions  are : 

1.  Stenosis  and  atresia  of  the  pulmonary  valve,  the  pulmonary 
artery  and  the  right  conus  arteriosus.  In  181  congenital  cases  he 
found  one  or  the  other  in  119. 

2.  Defective  auricular  septum. 

3.  Defective  ventricular  'septuru. 

These  may  exist  alone,  but  are  more  frequently  associated  with 
pulmonary  stenosis,  perforate  foramen  ovale,  and  pat^ilous  ductus 
Botalli,  in  the  order  named. 

4.  Congenital  lesions  of  the  tricuspid  orifice,  pure  or  associated. 

5.  Persistency  of  the  ductus  arteriosus. 

When  existing  alone,  may  be  found  at  an  advanced  age. 

6.  Congenital  narrowing  of  the  aortic  orifice. 

7.  Congenital  narrowing  of  the  mitral  orifice. 

The  number  of  valve  segments  is  sometimes  increased  or  dimin- 
ished. Increased  pulmonary  and  deficient  aortic  leaflets  occur  oftenest. 
Two  segments  may  be  fused,  in  which  case  thickening  as  a  rule  co- 
exists. Bicuspid  aortic  valve  has  been  oftenest  noted.  The  tendency 
to  vahoilar  disease  later  in  life  is  inci-eased  by  these  defects. 

Foetal  endocarditis  leads  to  sclerosis  and  thickening  of  the  edges 
and  to  shortening  of  the  chordre  tendinea?.  In  some  cases  the  results 
resemble  a  perforate  diaphragm,  especially  in  stenosis  of  the  pul- 
monary valve.  The  valve  may  be  rough  or  perfectly  smooth.  Smooth- 
ness is  taken  to  indicate  imperfect  development.  Roughness  indicates 
endocarditis.  The  sub.iects  often  die  of  tuberculosis.  Defective  sep- 
tum may  be  associated.  Congenital  aortic  defects  are  less  frequent 
than  pulmonary  lesions. 

Symptoms.     The  most  striking  .symptom  of  congenital  defect  of 


DISEASES    OF    THE    HEAET  223 

the  lieart  is  cyanosis,  which,  appears  soon  after  birth  and  is  permanent. 
It  may  be  of  slight  grade,  affecting  only  the  lips  and  finger  tips,  ears 
and  toes,  and  only  come  on  after  crying:  or  it  may  be  of  high  grade,, 
the  entii'e  body  exhibiting  a  bluish  or  purplish  lividity.  Clubbing  of 
the  fingers  and  toes  is  usual  and  extreme  and  the  nails  sharply  ciu-ve. 
Cough  and  dyspncea,  both  increased  by  slight  exertion,  are  generally 
present.  A  systolic  murmiu"  heard  over  the  auricles  and  absent  at  the 
base  indicates  the  lesion.  In  congenital  pulmonary  stenosis  the  second 
pvdmonary  sound  is  abnormally  weak  or  absent. 

DISEASES  OF  THE  :\.n:OCAEDIUM. 

Atrophy  of  the  heart  is  the  reverse  of  hypertrophy.  Diminution 
in  the  size  of  the  heart  keeps  pace  with  diminished  need.  It  is  con- 
genital or  acquired.  "Wasting  diseases  and  old  age  are  causes  of  the 
acquired  form.  The  wasting  which  accompanies  phthisis  is  a'  well- 
known  example. 

Physical  Signs.  "Weakened  impact,  usually  invisible,  small  weak 
pulse,  diminished  cardiac  area.  In  estimating  the  latter  the  influence 
of  emphysema,  so  often  present  in  old  age.  must  be  kept  in  mind.  The 
sounds  are  generally  weak  but  may  be  otherw'ise  normal.  In  phthisis 
the  second  pulmonary  sound  is  accentuated  despite  the  atrophy. 

HYPERTROPHY  AND  DILATATION. 

Cardiac  enlargement  occurs  in  three  forms : 

1.  Simple  hypertrophy,  in  which  the  walls  are  thickened  without 
any  change  in  the  size  of  the  cavities. 

2.  Hj-perti'ophy  with  dilatation :  dilatation  with  hypertrophy  or 
excentric  hj-pertrophy,  in  which  both  dilatation  of  the  cavities  and 
thickening  of  the  walls  are  present. 

3.  Simple  dilatation,  or  dilatation  of  the  cavities  with  thinning 
of  the  waUs.  It  is  manifest  that  if  the  walls  are  stretched,  they  must 
thin. 

The  weight  of  the  heart  has  been  given.  The  normal  thickness  of 
the  left  ventricle  is  from  one-third  to  one-half  inch ;  the  right  ventricle 
from  one-sirth  to  one-fourth  of  an  inch :  the  auricles  are  about  a  line 
in  thickness. 

The  thickness  of  the  left  ventricle  has  been  known  to  reach  an  inch 
and  a-half,  the  right,  three-fourths  of  an  inch  ia  thickness.  The 
aui-ieles  mav  double  their  normal  thickness  iu  extreme  cases. 


224  DlSK.VbES    OF    TJUli    UEAUT 

The  weight  of  the  heart  io  these  eases  varies  froii)  fifteen  to 
twenty-five  ounces,  except  in  such  extreme  cases  as  follows:  Stokes 
reports  a  heai-t  of  sixty-four  ounces :  Alonzo  Clark,  one  of  fifty-seven 
ounces;  Beverly  Eobinson,  one  of  fifty-three  ounces. 

Independently  of  cardiac  valvular  lesions  there  is  a  small  group 
of  hypertrophies  and  dilatations  which  deserves  notice.  They  are 
sometimes  designated  as  idiopathic,  as  opposed  to  the  hypertrophy 
caused  by  valvular  diseases.  Either  the  hypertrophy  or  the  dilatation 
may  be  primary,  but  eventually  the  one  condition  brings  about  the 
other,  hence  ultimately  th6y  co-exist. 

Causes.  Increased  labor  and  increased  intracardial  pressiu-e. 
The  part  affected  depends  on  the  part  called  upon  to  bear  the  strain. 
Mechanical  obstruction  to  the  circulation,  if  produced  suddenly,  brings 
dilatation,  if  brought  about  gradually,  hypertrophy  supervenes.  The 
left  vtotriele  is  primarily  affected  in  those  conditions  in  wliieli  the 
impediment  is  in  the  genei-al  arterial  cii-culation.  Such  arc  aiii'rio- 
sclerosis,  increased  intra-thoracic  pressure.  A  moderate  degree  of 
hypertrophy  exists  during  pregnancy,  according  to  Larcher.  Immod- 
erate athletic  exercise,  continued  use  of  alcohol,  particularly  beer 
(Striimpell),  and  all  forms  of  Bright 's  disease.  The  right  ventricle 
is  primarily  affected  when  the  causes  are  chiefly  the  outcome  of  im- 
peded pulmonic  circulation,  and  is  affected  secondarily  in  diseases 
■which  have  produced  the  same  condition  in  the  left  heart.  We  are 
of  the  opinion  that  also  associated  action  and  nerve  supplj'  is  responsi- 
ble for  a  considerable  amount  of  concurrent  hypertrophj'  in  these  cases 
as  well  as  in  vahiilar  diseases.  Nerve  and  nmscle  fibei's  are  in  large 
part  common  to  both  hearts  and  ability  to  disassociate  their  work  must 
needs  be  an  acquired  function. 

Right  hypertrophy  is  seen  as  a  result  of  undue  muscular  exercise 
in  athletes  and  soldiers  (Da  Costa). 

The  lung  group  embraces  emphysema,  cirrhosis,  phthisis  with 
consolidation,  and  pleuritic  adhesions.  Yet  left  hypertrophy  quite  as 
often  as  right  exists  in  these  eases. 

Hypertrophy  of  the  heart  as  a  whole  is  due  to  associated  causes, 
those  which  call  for  increased  work  of  both  sides:  Exophthalmic 
goitre,  certain  diseases  of  the  nervous  system,  excessive  use  of  cardiac 
stimulants,— tea,  coffee,  and  alcohol, — pericardial  adhesions,  as  as- 
serted by  Quain,  independent  of  valvular  diseases.  Sometimes 
pericarditis  is  the  cause  of  extreme  dilatation  without  hypertrophj*. 


DISEASES    OF    THE    HEART  225 

In  eases  where  dilatation  exceeds  hypertrophy,  some  form  of  myocar- 
dial degeneration  generalh'  will  be  found  to  co-exist. 

Sudden  death  with  acute  dilatation  in  infective  diseases,  and 
death  occurring  after  slight  exertion  during  convalesence,  are  probably 
so  caused.  The  dilatation  foimd  in  old  alcoholics  and  in  eases  of  wide- 
spread arterio-sclerosis  is  associated  with  fatty  infiltration,  fatty 
degeneration  or  fibroid  overgrowth.  Dilatation  which  supervenes 
upon  hypertrophy  in  valvular  diseases  is  probably  due  to  the  prone- 
ness  of  the  hyperti'ophied  muscle  to  undergo  degeneration. 

Simple  dilatation  is  most  often  observed  in  the  auricle  and  the 
right  ventricle. 

Symptoms  and  Physical  Signs.  As  long  as  the  balance  is  main- 
tained between  the  two  conditions  few  symptoms  present  themselves. 
There  may  be  some  dyspnoea,  and  vascular  throb  may  be  present  in 
the  neck.  In  failing  compensation  the  vascular  phenomena  described 
under  cardiac  lesions  supervene,  venous  repletion  and  congestion  of 
the  various  organs.    Headache,  giddiness  and  palpitation  are  frequent. 

Inspection.  Precordial  bulging,  especially  in  children,  cardiac 
impulse  displaced  outward  and  lowered  to  the  sixth  or  seventh  inter- 
space.   Dilatation  is  indicated  by  the  diffused,  wavy,  uncertain  stroke. 

Palpation.  The  impulse  may  be  double,  one  systolic,  one  diastolic. 
Pulse  regular,  full,  tense  in  hypertrophy;  weak,  irregular  and  more 
frequent  in  dilatation. 

Percussion  shows  area  of  increase. 

Auscultation.  In  hypertrophy  the  first  sound  is  dull,  heavj^ 
prolonged  and  sometimes  reduplicated.  Laennec  called  attention  to  a 
click,  sometimes  heard  in  the  young. 

In  dilatation  the  quality  of  the  first  sound  approaches  that  of  the 
second,  the  pause  shortens  and  we  have  a  simulation  of  the  foetal  heart 
sounds,  called  by  the  French,  embryocardia.  Frequently  the  canter 
2'hythm,  or  hruit  de  galop,  is  present.  Murmurs  are  absent  unless  the 
condition  results  in  valvular  incompetency. 

Diagnosis.     Four  points  are  insisted  upon : 

Increased  area. 

The  heaving  or  difiiused  impulse. 

Absence  of  murmur. 

Character  of  the  sounds. 

Acute  myositis,  abscess  of  the  heart,  aneurysm  of  its  walls,  fatty 


226  DISEASES    OF    THE    HE^VRT 

changes,  acute  myocarditis,  give  rise  to  uo  distinctive  signs  in  tiunn- 
selves,  but  may  bring  about  results  which  are  recognizable. 

Fibroid  heart  (myocarditis)  is  followed  by  a  train  of  symptoms 
due  to  the  i-esulting  dilatation  and  venous  congestion.  It  is  usually  a 
part  of  endocarditis.  Its  physical  signs  are  those  of  dilatation.  A 
variable  and  unstable  mitral  murmur  may  be  jiresent  without  accentu- 
ation of  the  second  pulmonic  sound. 

ACUTE  ENDOCARDITIS. 

Dcfiniiion.  Indammatiou  of  the  lining  membrane  of  the  heai-t. 
The  valves  are  usually  involved,  though  the  lining  membrane  of  the 
cavities  and  the  chorda?  tendineffi  may  be  aft'ected  alone.  That  the 
latter  condition  is  not  as  rare  as  might  be  supposed  is  proved  by  the 
statistics  of  the  Koyal  College  of  Physicians,  in  which  series  of  cases, 
the  walls  were  affected  33  times  in  209  cases. 

It  is  usual  to  distinguish  two  varieties  of  the  disease,  a  simple 
and  a  malignant  form,  but  in  reality  the  distinction  is  one  of  degree 
rather  than  of  anatomical  difference. 

Simple  or  benign  endocarditis  always  arises  in  the  course  of  some 
other  disease.  Rheumatism  plays  the  chief  role,  with  pneumonia 
second.  Tonsillitis  and  scarlet  fever  are  liable  to  the  complication. 
Other  infectious  diseases  less  frequently  show  it,  but  the  possibility 
of  its  occurrence  as  a  late  complication  must  not  be  forgotten.  Attacks 
during  the  course  of  phthisis  are  not  rare.  The  causal  relationship  of 
chorea  to  endocarditis  in  eai-ly  life  can  not  be  denied,  and  a  large 
proportion  of  patients  who  have  been  afflicted  with  the  foi-mer  carry 
the  lesions  of  the  latter  malady. 

The  malignant  tj-pe  may  exist  as  an  independent  disease,  but 
secondary  forms  ai-e  more  usual.  In  infective  diseases,  pneumonia  and 
kidney  diseases  the  malignant  variety  is  prone  to  occur. 

While  in  rheumatism,  as  in  pneumonia,  the  benign  type  is  oftenest 
met  with,  yet  the  malignant  form  is  not  rare  in  either  disease. 

Septic  infective  diseases  furnish  a  proportion  of  the  cases. 

Symptoms.  Simple  endocarditis  gives  rise  to  no  distinctive  symp- 
toms or  physical  signs.  In  the  course  of  inflammatory  diseases  in- 
creased rapidity  and  irregularity  of  the  heart's  action  and  increased' 
fever  without  assignable  cause  are  suspicious. 

A  murmur  at  the  apes  may  develop  but  its  presence  does  not 
indicate  the  disease,  nor  does  its  absence  mean  exemption.     The  stu- 


DISEASES    OF    THE    HEAET  227 

dent  must  free  his  mind  of  the  widespread  fallacy  that  heart  affections 
must  needs  be  attested  by  miirmm-s. 

The  malignant  form  is  manifested  by  rigors,  sweats,  irregular  or 
intermittent  fever,  delirium  and  sig-ns  of  septic  infection,  which  are 
in  no  way  distinctive  of  heart  involvement.  Another  tj'pe  is  the 
typhoid,  which  is  self-explanatory. 

In  persons  known  to  have  chronic  ^■ah-ular  lesions,  symptoms  sim- 
ilar to  the  above  should  excite  grave  apprehensions  of  a  recurrent 
endocarditis.  Embolic  sjTuptoms  often  occur  and  aid  the  diagnosis. 
The  disease  is  perhaps  most  often  mistaken  for  typhoid  fever.  Widal's 
reaction  excludes  the  latter. 


SECTION  XI. 

THORACIC  ANEURYSM. 

All  aiuniiysin  is  a  more  or  less  circumscribed  dilation  of  au 
artery.  The  dilation  may  include  all  the  coats  of  the  artery,  or  it 
may  be  that  one  or  two  coat.s  having  yielded  or  ruptured,  the  remaiuiug 
part  dilating  thus  forms  a  blood  sac  which  communicates  with  the 
parent  vessel. 

A  convenient  division  of  these  lesions  is  into  internal,  or  medical, 
and  e-\ternal,  or  surgical,  aneurysms,  which  classification  is  self- 
explanatory. 

Aneurysm  of  the  thoracic  portion  of  the  aorta  is  by  far  the  most 
frequently  met  with  among  aneurysms,  since  aneurysms  of  the 
aorta  follow  the  same  law  as  does  sclerosis  with  regard  to  situation, 
viz.,  the  nearer  the  heart  the  greater  the  pressure,  hence  the  greater 
the  liability  to  aneurysm.  For  this  reason  they  are  oftenest  found  in 
the  ascending  portion  of  the  arch,  which  is  the  subject  of  attack  five 
times  as  frequently  as  the  abdominal  aorta:  then  in  the  transverse 
and  descending  portions,  where  they  occur  three  times  as  often  as  in 
the  abdominal  vessel.  For  the  same  reason  they  are  found  on  the 
.convexity  of  the  arch,  rarely  on  the  concave  side. 

Anatomy.  The  aorta  lies  in  the  middle  mediastinum.  It  arises 
from  the  base  of  the  left  ventricle,  behind  the  left  margin  of  the 
isternum,  opposite  the  lower  border  of  the  third  left  costal  cartilage. 
'This  point  corresponds  to  the  body  of  the  fifth  dorsal  vertebra.  It 
pas.ses  upwards,  forwards  and  to  the  right,  between  the  superior  vena 
cava  and  the  pulmonary  artery,  as  far  as  the  right  border  of  the 
sternum,  beyond  which  it  does  not  project,  and  as  high  as  the  second 
costal  cartilage.  Its  breadth  is  28  m.  m.  At  the  point  given  it  arches 
upwards,  backwards  and  to  the  left,  winding  around  the  trachea  to 
reach  its  left  side,  whence  it  passes  to  the  left  side  of  the  lower  border 
of  the  fourth  dorsal  vertebra,  where  it  becomes  the  descending  aorta, 
which  ends  at  the  opening  of  the  diaphragm.  The  trachea  lies  first 
behind  the  aorta,  then  to  its  right  side,  within  the  curve  of  its  ai"ch. 


THORACIC    AXEURTSil  229 

BifiU'cating  at  the  lower  border,  the  left  bronchus  passes  beneath  the 
arch.  The  left  phrenic  and  pneiuaogastrie  nerves  pass  in  front  of  the 
arch:  the  left  reeiu-rent  laryngeal  winds  under  it;  the  right  pneiimo- 
gastrie  passes  behind  it.  The  cesophagus  lies  behind  the  arch  at  first, 
between  the  trachea  and  the  border  of  the  vertebra?,  then  to  the  right 
of  the  descending  aorta. 

Inspection  in  the  early  stages  reveals  nothing.  Sooner  or  later, 
however,  a  fullness  is  apparent  over  the  anterior  portion  of  the  chest 
above  described,  varying  with  the  seat  and  size  of  the  tumor.  It  may 
be  merely  a  fullness,  or  it  may  be  a  prominent  elevation  of  one  or  more 
ribs,  the  inner  end  of  the  clavicle  or  of  the  sternum.  The  bulging  most 
frequently  occurs  to  the  right  of  the  sternum  in  the  second  or  third 
interspaces,  or  even  as  high  up  as  the  end  of  the  clavicle  if  the  tumor 
be  of  the  ascending  limb,  or  lies  behind  the  manubrium,  when  the 
transverse  arch  is  affected.  Tumors  of  the  descending  arch  may  cause 
bulging  to  the  left  of  the  sternum,  but  are  less  likely  to  do  so  until  they 
have  attained  a  very  considerable  size,  owing  to  the  greater  depth  of 
the  descending  portion  of  the  structure. 

Palpation  reveals  an  area  more  resistant  than  the  surrounding 
region,  and  a  distinct  pulsation  may  be  eommiinicated  to  the  super- 
imposed finger-tips  which  seems  to  come  from  beneath.  In  advanced 
cases  this  impact  gives  the  sensation  of  dilation  or  expansion  of  the 
tumor  mass :  at  other  times  a  sensation  which  is  best  described  by  the 
word  "heaving."'  It  is  almost  sj-nchronous  with  cardiac  systole,  but 
is  differentiated  from  the  heart  by  its  character  and  location.  It  may 
be  feeble,  or  may  seem  stronger  than  the  heart-beat  itself.  Its  location 
is  directly  behind  the  sternum  opposite  the  second  interspace,  or  is 
felt  in  the  second  interspace,  either  to  the  right  or  to  the  left  of  the 
sternum,  being  a  little  lower  on  the  right  side  than  on  the  left.  In 
case  calcification  of  the  sac  has  taken  place  this  expansile  impact  is 
wanting,  as  the  elasticity  of  the  sac  is  thereby  destroyed.  Where  a 
laminated  clot  partially  fills  the  sac  the  same  observation  applies  in 
varying  degrees :  but  in  both  cases  impact  often  remains. 

Percussion  reveals  an  area  of  dullness  corresponding  to  the  en- 
largement. Its  situation  is  that  of  the  aorta,  and  lies  higher  than  the 
base  of  the  heart,  from  which  it  is  sometimes  separated  by  a  narrow 
isthmus. 

Auscultation.  Sometimes  nothing  is  heard  over  the  tximor  except 
the  transmitted  heart  sounds.    Both  sounds  may  be  heard,  or  only  the 


230  THORACIC    ANEURYSM 

first  sound,  which  is  then  generally  accentuated  and  |)r()longed. 
Careful  comparison  should  be  made  with  the  sounds  heard  over  the 
apex  beat  as  to  the  time  and  duration  of  the  aneurysmal  sounds.  Two 
other  sounds  are  intimately  associated  with  aneurysm,  and  while  their 
presence  means  nnieh  their  absence  does  not  indicate  that  the  tumor 
is  not  aneui-ysmal.  These  sounds  are  the  thrill,  which  is  more  apt  to 
be  present  when  the  vessel  is  the  seat  of  extensive  atheroma ;  and  the 
bruit,  which  is  the  name  given  to  the  whirl  of  blood  within  the  dilation 
or  sac.  This  sound,  which  is  the  one  most  commonly  heard  over  an 
aneurysm,  is  synchronous  with  systole,  generally  single,  and  is  of  short 
duration. 

The  most  positive  single  sign,  therefore,  of  aneurysm,  is  an  impact 
or  pulsation  within  the  above-described  area,  which  is  independent  of 
the  heai't  and  which  is  accompanied  by  its  own  sounds.  These  sounds 
are  superficial  in  character,  unlike  those  produced  by  a  new-growth 
pressing  downward  from  the  surface  upon  the  aorta,  in  which  case  also 
a  deep-seated  murmur  may  be  heard  over  the  course  of  the  aorta. 

Fluoroscopic  exmaninatiou  and  radiographs  often  make  certain 
the  diagnosis  of  aneurysm  when  the  physical  signs  fail  to  reveal  its 
presence,  as  noted  in  Section  XVII.  This  is  especially  the  case  when 
clot,  partly  obliterating  the  sac,  modifies,  or  causes  to  disappear  most 
of  the  auscultation  signs;  whereas  the  solidification  renders  the  tumor 
more  apparent  in  the  radiogi-aph. 

Pressure  Symptoms.  There  is  but  little  unoccupied  space  within 
the  chest,  and  any  enlargement,  whether  it  be  of  existing  organs  or  a 
new-gro\^'th,  is  sure  to  trespass  upon  some  of  its  neighbors  and  give 
rise  to  pressure  sjnnptoms.  The  diagnostic  value  of  this  symptom 
group  will  be  appreciated  when  we  consider  Bramwell's  ornate  classi- 
fication of  aneurysms  into  three  groups : — aneurysms  which  are  latent 
and  give  no  physical  signs;  aneurysms  which  present  signs  of  intra- 
thoracic pressure,  but  not  sufficiently  definite  to  determine  the  nature 
of  the  lesion ;  aneurysms  which  produce  distinct  tiimors,  physical  signs 
and  pressure-symptoms. 

From  their  nature  and  situation,  aneury-sms  of  the  arch  are  most 
prone  to  press  upon  the  trachea,  giving  rise  to  dyspncEa,  cough  and 
shortness  of  breath.  The  cough  has  a  peculiar  ringing  quality  which 
may  be  mistaken  for  chronic  afliection  of  the  larynx.  It  may  be  dry, 
or  may  be  accompanied  by  profuse  watery  or  muco-purulent  expec- 
toration, by  rales  and  other  signs  of  bronchitis.     The  voice  may  be 


THOKACIC    .IXEUETSM  231 

«tridulous,  hoarse  and  croaking,  and  the  sentence  often  ends  in  a  pecu- 
liar gasp.  Both  inspiration  and  expiration  are  equally  affected.  If 
the  oesophagus  be  pressed  upon,  we  get  dysphagia.  Inequalities  of  the 
two  radial  ptdses  are  not  infrequent,  due  to  pressure  upon  the  sub- 
clavian. Sometimes  inequalities  of  pupils  are  noted.  These  signs  may 
be  present  in  case  of  mediastinal  new-growths,  but  in  such  case  the 
pulsation  is  absent.  Furthermore,  aneurysm  is  by  far  the  most  com- 
mon intra-thoraeic  tumor.  (S%Tnptoms  caused  by  mediastinal  growths 
are  considered  in  a  separate  paragi-aph.) 

Pain  is  a  prominent  and  frequently  an  early  symptom.  At  first 
the  pain  may  be  fugitive  but  gradually  becomes  more  and  more  con- 
stant and  varies  in  intensity  and  character  with  the  structures  pressed 
upon.  Violent,  recurrent  pains  within  the  thoracic  ca^-ity.  especially 
if  shooting  up  into  the  neck  and  arms,  or  pain  of  a  boring  character, 
should  excite  the  suspicion  of  aneurysm,  ilen  are  much  more  fre- 
quently attacked  than  women,  and  the  selective  age  is  between  35 
.and  45  years. 

Aneurysms  of  the  Ascending  Portion  of  the  Arch.  Aneurysms 
of  this  portion  of  the  arch  may  push  the  heart  downwards  and  to  the 
left.  They  involve  most  frequently  the  right  recurrent  larrageal 
nerve,  the  vena  cava  superior,  sometimes  the  inferior  cava,  or  the 
right  subclavian  vein.  The  result  of  such  involvement  is  widespread 
<Edema.    The  innominate  artery  usually  escapes. 

Aneurysms  of  the  Transverse  Arch.  These  tumors  occupy  the 
middle  line  or  project  to  the  right  much  more  often  than  to  the  left. 
They  involve  the  trachea,  left  larjTigeal  nerve  and  the  innominate 
artery.  The  radial  and  carotid  pulse  may  be  absent.  They  may 
•attain  enormous  size,  pro.jectrQg  into  the  sternal  notch.  The  pressure 
symptoms  vai-y  but  correspond  nearly  to  those  given.  The  pupils  may 
be  at  first  dilated,  but  later  contracted  or  unequal. 

Aneurysms  of  the  Descending  Portion  of  the  Arch.  The  sac  pro- 
jects backwards  and  erodes  the  bodies  of  the  thoracic  vertebrae,  or  the 
tumor  appears  imder  the  left  scapula.  It  gives  rise  to  an  area  of  per- 
•cussion-didlness  in  the  left  spinal  gutter,  from  the  third  to  the  sixth 
■dorsal  vertebra.    Dysphagia  is  common. 

Aneurysms  of  the  Descending  Thoracic  Aorta.  These  occur  gen- 
•erally  just  above  the  diaphragm.  Such  a  tumor  is  more  difficult  of 
•detection  than  aneurysm  of  the  arch,  beeaxise  the  majority  of  the 


232  THORACIC    ANEURYSM 

pressure  syiii|)toni.s  are  absent  and.  by  reason  nf  its  tleeper  seat,  pulsa- 
tion can  not  be  detected  nearly  so  early. 

The  pain  is  usually  of  a  gnawing  character,  due  to  absorption  of 
the  bodies  of  the  vertebra;.  This  is  one  of  the  most  characteristic  .symp- 
toms. So  situated,  the  growth  may  simulate  lumbago,  intercostal 
neiiralgia  or  back-ache;  the  latter,  especially  in  women,  is  an  ailment 
so  common  as  ordinaril.y  to  excite  little  notice. 

Aneurysm  of  the  Innominate  Artery.  An  aneurysm  of  the  trans- 
verse portion  of  the  arch  may  involve  the  innominate  and  left  common 
carotid,  but  the  innominate  is  sometimes  affected  alone.  Here  the 
tumor  is  situated  above  the  second  interspace  and  behind  the  sterno- 
clavicular articulation.  Most  of  the  pressure  signs  descril)ed  are  ab- 
sent. Compression  of  the  subclavian  and  right  common  carotid,  made 
with  the  fingers  on  the  affected  side  diminishes  the  pulsation  in  the 
tumor. 

SPECIAL  DIAGNOSTIC  SIGNS  OF  ANEURYS^M. 

The  Tracheal  Tug.  This  sign  was  pointed  out  by  Surgeon  Major 
Oliver,  U.  S.  A.,  is  frequently  present  and  is  a  most  valuable  sign. 
Place  the  patient  with  the  head  bent  slightly  forward  to  relax  the 
tissues  of  the  neck.  Draw  the  cricoid  cartilage  upwards  with  the 
thumb  and  finger  sufficiently  to  gently  stretch  the  trachea.  At  each 
heart-throb  a  distinct  downward  movement  of  the  cricoid  (tug)  wiU 
be  felt  and  often  seen,  synchronous  with  the  systole.  The  tugging  is 
strongest  when  the  growth  presses  against  the  left  bronchus.  The  sign 
is  especially  apt  to  be  obvious  when  the  aneurysm  affects  the  trans- 
verse portion  of  the  arch,  particularly  its  posterior  part,  and  is  said 
to  be  absent  in  aneurysm  of  the  innominate,  thus  serving  to  differ- 
entiate the  two  conditions.  The  anatomic  i-elations  given  make  clear 
the  reasons  of  its  production.  It  may  be  the  sole  sign  of  the  malady, 
and  .should  therefore  always  be  searched  for.  It  is  sometimes  present 
comparatively  early  in  the  disease. 

H.  L.  Smith  directs  attention  to  a  sign  which  he  has  found  to  be 
present  in  several  cases.  "This  sign  is  elicited  by  combined  palpation 
and  percussion  as  follows :  The  cricoid  cartilage  is  grasped  as  is  done 
for  tracheal  tugging,  while  an  assistant  percusses  the  chest.  "When 
-normal  parts  are  percussed  the  palpating  hand  feels  a  distant,  feeble 
.iar  (proximal  ends  of  the  clavicles  excepted),  but  so  .soon  as  the 
aneurvsmal  area  is  reached,  a  shock  which  is  both  direct  and  resilient 


THORACIC    ANEURYSM  233 

in  nature  is  felt,  somewhat  suggestive,  as  I  take  it,  of  the  sensation 
experienced  by  one  when  a  rubber  bag  filled  with  water  is  simulta- 
neously palpated  and  percussed." 

In  the  one  opportunity  afforded  me  since  seeing  the  above,  I  have 
been  able  clearly  to  elicit  the  sign. 

Special  Symptoms.  Pain  is  characteristic  of  the  disease.  Gener- 
ally constant,  it  is  however  subject  to  severe  exacerbations,  due  ta 
pressure  exerted  directly  on  nerves  or  to  stretching  of  the  nerve  fila- 
ments of  the  sac.  Shooting  and  darting  pains  over  the  involved  area, 
or  over  a  considerable  portion  of  the  chest,  the  neck,  the  occiput  and 
down  the  arms,  especially  the  left,  to  the  finger-tips,  denote  pressure 
on  contiguous  structures ;  while  unremitting  dull,  boring  pain  denotes 
that  erosion  of  bone  is  taking  place.  This  applies  especially  to  tumors 
of  the  descending  limb,  in  which  the  vertebrte  are  transgressed  upon. 
Aneurysms  involving  the  transverse  portion  of  the  arch  produce  the 
severest  pressure  symptoms,  because  of  the  narro^^Tiess  of  the  antero- 
posterior diameter  of  the  chest  and  the  important  structures  in  inti- 
mate relation  with  this  division  of  the  arch,  which  are  readily  com- 
pressed as  soon  as  the  growth  attains  any  considerable  size.  Growths 
of  the  descending  aorta  may  cause  pain  in  the  intercostal  spaces  which 
is  liable  to  be  mistaken  for  neuralgia.  Anaesthesia  of  the  skin  fre- 
quently accompanies  this  pain. 

DyspncBa  is  due  to  pressure  upon  nerve  trunks,  vessels,  lung, 
bronchi  or  trachea,  and  is  not  necessarily  in  proportion  to  the  size  of 
the  tumor.  It  is  least  when  the  pressure  is  directly  exerted  upon  lung 
substance,  when  physical  signs  of  consolidation  and  collapse  of  pul- 
monary tissue  may  co-exist  with  only  slight  dyspnoea.  On  the  other 
hand,  pressure  upon  the  trachea  or  on  one  bronchus  will  occasion 
severe  dyspnoja,  amounting  to  orthopnoea.  Such  pressure  is  indicated 
by  noisy,  stridulous  breathing,  loud  clanging  cough  and  expectoration. 
Various  rales,  from  retained  secretions;  imperfect  expansion  of  the 
affected  side;  diminished  tactile  fremitus;  feeble  or  absent  breath 
sounds,  with  slight  fever  are  noted  on  examination,  and  may  suggest 
phthisis,  as  pointed  out  by  Hanot. 

Sudden  and  severe  paroxysms  of  dyspnoea,  due  to  increase  of 
pressure  when  the  sac  distends;  asthmatic  seizures  resulting  from  im- 
plication of  the  vagus,  particularly  the  recurrent  laryngeal  branch, 
are  common  phenomena  and  may  suggest  angina  pectoris.  (Pepper 
holds  that  true  angina  may  be  associated.) 


234  TIldRACIC    ANEURYSM 

Laryngeal  symptoms  are  common,  such  as  spasm  of  the  larynx, 
dyspnu'a  and  stridor,  or  paralysis  of  one  or  both  vocal  cords,  with 
husky  or  whispering  voice,  or  aphonia.  Pressure  on  the  left  recurrent 
laryngeal  nerve  causes  most  of  these  alterations,  viz.,  imperfect  vocal- 
ization, aphonia,  hoarseness  and  varying  degrees  of  paralysis  of  the 
vocal  cords.  Pressure  on  the  right  side  of  the  trachea  does  not  affect 
this  nerve,  and  therefore  aphonia  and  dysphagia  are  absent  although 
the  voice  may  be  strident  ( Tuf nell ) . 

Cough.  The  cough  is  apt  to  come  on  in  paroxysms,  and  is  loud, 
brassy,  stridulous  or  ringing.  In  an  impressive  case  recently  seen  the 
patient  could  only  phonate  with  inspiratory  gasps.  During  the  attacks 
the  cough  was  stridulous  but  ringing,  dyspnoea  intense,  yet  with  inter- 
vals of  relief.    The  case  was  verified  by  autopsy. 

Dysphagia  is  a  rarer  symptom,  but  occurs  especially  in  cases  of 
aneurysm  of  the  descending  division,  exerting  jiressuie  on  the 
CESophagus. 

Alterations  of  the  pupils  are  frequently  concomitant;  dilatation 
■occurring  when  the  cervical  sympathetic  ganglia  are  irritated  by  slight 
pressure,  contraction  intervening  when  the  pressure  causes  paralysis. 
Hence  dilatation  is  an  early  symptom;  contraction  a  late  one.  The 
phenomenon  is  limited  to  the  affected  side.  When  exophthalmos  occurs 
it  is  usually  bi-lateral.  Unilateral  sweating,  local  areas  of  flushing,  of 
anaesthesia,  paleness,  or  coldness  of  the  skin  are  occasionally  en- 
countered. 

Congestion,  cyanosis  and  particularly  oedema  result  from  pressure 
on  the  superior  vena  cava  and  are  frequent.  It  may  affect  the  head 
and  neck,  or  be  limited  to  one  pectoral  or  one  arm.  Such  redematous 
or  spongy  masses  occurring  at  the  base  of  the  neck,  above  the  clavicles, 
have  been  termed  "the  collar  of  flesh",  and  are  unmistakable. 

Puhe.  A  veiy  old,  yet  very  valuable,  sign  of  aneurysm  is  alter- 
ation in  the  pulse,  causing  delay  in  the  pulse  wave  or  eveu  total  obliter- 
ation. The  sign  is  valuable  owing  to  the  ease  and  certainty  with  which 
it  may  be  tested.  Thus,  in  health  the  two  radial  pulses  are  synchro- 
noiis,  but  in  aneurysm  affecting  the  innominate  artery  the  right  pulse 
may  lag,  while  one  affecting  the  left  common  carotid  and  subclavian 
will  cause  the  left  pulse  to  be  retarded.  The  retardation  may  be  ex- 
plained by  the  temporary  interruption  of  maintained  pressure  in  the 
blood  current,  on  reaching  the  empty  sac,  which  acts  as  a  miniature 
reservoir,  and  the  resumption  of  pressure  as  soon  as  the  sac  is  dis- 


THORACIC    AJyTECETSil  235 

tended.  Xarrowing  of  the  exit  from  the  sac  woiild  also  canse  delay 
by  retarding  the  blood  exit. 

The  accentuation  of  the  aortic  second  sound  so  often  noticed  in 
•eases  of  thoracic  aneurysm  is  due  to  the  augmented  back-flow  of  blood 
against  the  semilunar  valves.  The  increment  to  the  wave  being  derived 
from  the  aneurysmal  reservoir. 

Differential  Diagnosis.  New-growths  situated  in  the  mediasti- 
num, enlargements  of  the  heart,  effusions  into  the  left  pleura  causing 
upward  displacements  of  the  heart,  may  be  mistaken  for  aneurysm. 
In  aneurysm  the  tumor  is  above  the  base  of  the  heart  and  the  area  of 
dullness  caused  by  its  presence  is.  often  separated  from  the  heart  by 
intervening  lung  or  joined  to  it  by  a  narrow  band.  Its  auscultation 
sounds  are  separate  from  those  of  the  heart  and  possess  different 
qualities.  Effusions,  while  lifting  the  heart  upward,  are  not  accom- 
panied by  bruit  or  thrill ;  the  heart  sounds  are  feeble  and  distant,  the 
apex  displaced.  Xew-growths  give  rise  to  pressure  sjTnptoms  but 
other  signs  are  absent. 


SECTION  XII. 

EXAMINATION  OF  THE  BLOOD. 

Recent,  advances  made  in  our  knowledge  oi'  the  causes  of  disease 
have  been  due  not  a  little  to  the  study  of  the  blood.  The  blood  changes 
which  accompany  disease  are  of  such  momentous  import,  and  their 
recognition  contributes  so  much  of  inestimable  value  to  the  field  of 
diagnosis,  as  well  as  to  pi-ognosis  and  cure,  that  it  is  the  duty  of  every 
physician  to  be  able  to  recognize  these  departures  from  the  normal, 
and  to  interpret  their  significance. 

The  present  chapter  will  consider  only  the  inoi'c  cuiiniioiily  oc- 
curring changes  and  those  which  fall  within  the  province  of  the 
general  practitioner,  omitting  such  investigations  as  require  unusual 
and  costly  apparatus  or  the  privileges  of  a  well-equipped  laboratory. 

Normal  Blood  Elements.  By  proper  manipulation  the  blood  may 
be  readily  separated  into  a  clear  fluid,  the  plasma,  and  the  solid  or 
corpuscular  constituents.  These  are  the  red  corpuscles,  or  erythro- 
cytes, the  colorless  corpuscles,  or  leucocytes,  and  the  eoloi'less  discs,  or 
blood-plaques  of  Bizzozero. 

Place  a  drop  of  blood  on  a  glass  slide,  cover  and  examine  with 
the  microscope.  The  red  corpuscles  form  rouleaux,  and  their  color  is 
pale  greenish-yellow.  Their  average  diameter  7.5  /j..  The  rouleau  ten- 
dency diminishes  when  their  number  is  below  normal.  Red  cells,  larger 
than  normal  (diam.  9.5  to  12.)  are  called  maerocytes  or  megalocytes, 
those  .smaller  than  normal  are  called  microeytes  (diam.  3.5  to  6)  while 
those  of  irregular  shape  are  called  poikilocytes.  These  may  manifest 
motilitj'.  The  leucocytes  are  seen  here  and  there  in  the  spaces  between 
the  red  rows.  Staining  shows  them  to  be  nucleated  and  generally  gran- 
ular, irregular  in  shape,  larger  than  the  red  cells  and  cajiable  of  loco- 
motion.    Their  varieties  will  be  considered  later. 

In  addition  to  the  above  elements  the  student  should  .search  care- 
fulty  for  abnormal  constituents,  both  -within  and  without  the  cells,, 
such  as  pigment  granules,  malarial  organisms,  filaria,  spiroehtetes  and 
other  parasites. 


»f^ 
^^S''" 


WW 


MftST    CELLS 


Neutrophilic  MY£Loc\Tes 


E 


J,       EOSINOPHILIC 

MfELoCYTES 


.,_,^  fOLyivjoj^PHOfJu  CLEAR 

ll^  ^  Leucocytes 


POLyNUCLe/»B, 
Eo^l/^opHlLlC     LEC/COCYTES. 


PLATE  XVII. 


EXAMINATION    OF    THE    BLOOD  237 

A  material  increase  of  any  particular  cell -element  is  spoken  of  as 
■ —  'osis,  hence  the  term  leucocytosis,  microcji;osis,  etc.  IMicrocj-thEemia, 
megalocji;hffimia,  etc.,  have  the  same  significance. 

To  give  a  detailed  description  of  the  varioiis  cells  found  in  the 
blood  in  disease  were  impossible  within  the  limits  of  this  brief  treatise, 
and  would  serve  a  less  useful  purpose  than  the  accompanying  classi- 
fication with  attached  nomenclature. 

The  Red  Corpuscles.  The  red  cells  are  circular,  bi-concave  discs 
of  greenish-yellow  color  and  non-nucleated.  The  average  diameter  is 
7.5  IX.  The  center  being  thinner  than  the  rim  is  therefore  lighter 
colored.  Abnormal  pallor  can  be  detected  by  practice.  There  is  less 
variation  in  the  size  and  shape  of  the  red  than  of  the  white  cor- 
puscles. Moving  cells  are  seen  to  change  their  shape,  like  elastic  bags. 
Macroeytes  are  probably  regenerative  cells;  microcytes,  degenerative. 

The  name  poikilocytes  was  given  by  Quincke  to  irregular  forms 
sometimes  seen  elongated,  balloon-shaped,  rod-like,  which  occur  in 
severe  ansemias  and  in  chlorosis.  Crenation,  which  occurs  upon  the 
slide,  is  the  ameboid  motion  with  change  of  shape,  and  is  outside 
poikiloeji;osis.  The  absence  of  the  rouleau  tendency  is  sometimes 
noticeable,  and  is  seen  in  pneumonia,  hepatic  diseases  and  nephritis. 
Polycythemia  is  an  actual  increase  in  the  number  of  red  blood  cor- 
puscles. It  is  relative  when  due  to  a  diminution  of  the  plasma,  as  in 
diarrhoeas  and  ascites.  The  opposite  condition  is  kno%vn  as  oligocy- 
thiemia  and  occurs  in  the  antemias,  septicemia  and  all  wasting  diseases. 

Normal  red  cells  show  little  affinity  for  dyes,  differing  in  this 
respect  from  the  white  cells.  In  disease,  red  cells  which  accept  stains 
are  met  with,  also  cells  not  normally  present  in  health  but  seen  in  dis- 
ease, as  the  microcj-tes  and  the  megalocji:es  which  stain  readily. 
Staining  with  methylene  blue  shows  the  granular  nature  of  diseased 
and  degenerated  red  cells.  Cells  containing  such  granules  occur  in 
pernicious  anemia,  malaria,  the  leukemias,  and  lead  poisoning.  In 
the  last  they  are  very  constant,  and,  in  the  absence  of  the  other  condi- 
tions, saturnism  should  be  suspected. 

Nucleated  red  cells  are  found  in  the  foetus  and  immediately  after 
birth,  and  at  all  times  in  the  bone-marrow.  Three  varieties  are 
described : 

(a)  Normoblasts. 

(b)  Megaloblasts  and 

(c)  Mieroblasts. 


238  EXAMINATION    OF    TILE    BLOOD 

The  first  is  a  developmental  form  of  the  uorniooyte.  In  other 
words  it  is  an  immature  red  blood  corpuscle.  Megaloblasts,  cells  of 
10  n  or  over,  occur  only  in  disease.  They  are  not  found  in  healthy 
marrow.  They  are  seen  in  anajmias  due  to  intestinal  parasites,  in 
grave  antemias,  especially  when  pernicious.  Ehrlich  considers  their 
occurrence  as  prognosticating  death,  except  in  parasitic  anemia. 
Microblasts  are  rarer  than  the  above,  they  are  of  small  size, 
imperfect  form  and  their  import  equally  serious.  Both  forms  seem  to 
indicate  a  return  to  the  ftctal  type  of  blood. 

The  following  terms  are  used  to  describe  the  behavioi-  of  all  cells 
towards  the  various  dyes  employed : 

Basophilic,  having  an  affinity  for  basic  dyes. 

Achromatophilic,  no  affinity  for  dyes. 

Oxyphilic,  having  an  affinity  for  acid  dyes. 

Polyehromatophilic,  an  affinity  for  both  basic  and  acitl  il\i's. 

Xevitrophilic,  having  an  affinity  for  neutral  dyes. 

Eosinophilic,  having  an  affinity  for  eosin  stain. 

Chromotrophic  elements  are  stained  a  different  color  from  that  of 
the  dye,  as  when  violet  dyes  stain  red. 

The  White  Corpuscles,  or  leucoc>-tes.  are  colorless  cells.  They 
are  generally  larger  than  the  red  bodies,  more  irregular  in  shape,  are 
nucleated  and  much  fewer  in  number  than  the  red  cells.  From  their 
composition  they  are  divided  into  granular  and  non-granular  varie- 
ties, or  may  be  classified  as  mono-nuclear  and  poly-nuclear  forms.  The 
larger  varieties,  especially  the  coarse  granular  cells,  are  actively  ame- 
boid, the  small  mono-nuclear  variety  is  devoid  of  ameboid  move- 
ment. 

Classified  in  accordance  with  their  origin,  two  groups  may  be 
distinguished : 

I.  Those  from  the  bone-marrow,  the  myelogenous  group,  and 

II.  Those  from  the  adenoid  tissue,  the  lymphogenous  group.  This 
second  gi'oup  comprises  the  lymphocytes  of  all  sizes. 

The  first  group  includes  the  following: 

(a)  Polymorphonuclear  neutrophiles. 

(b)  Eosinophiles, 

(c)  Mast  cells, 

(d)  Large  mononuclear  cells  of  Ehrlich. 
The  forms  of  group  I  are  not  transitional. 


LftR&E  LYMPHOCYTES 


MYELOCYTES 


SMRLL 


LYMPHOtYTLS(^ 


#-^  I 


^^A    POLY  MofsPHOt^oc  LEAK 
ritUTROPHILt 

SHOWS  Ko  p^oToe\.l^s^'^  (fiecRoTit'!) 
EOilHOPHlLE. 


lONtUTRoPHILIC 

POLYMutlEfl!*. 

LtUCOCYTE. 


LYNiPvocyres 


9 


LYmPhocYtE 


f-r^tfe. 


^ 


iJ? 


I  1+  VSt^  LEUCOCYTE, 

LYMMoCyTe   ' 


LYJ^fHotYTE 


RED    CELLS 


RED   CELLS  AND    POLYMORPHONUCLEAR    NEUTROPHILES 


PLATE   XVIII. 
VARIETIES  OF  LEUCOCYTES. 


EXAMINATION    OF    THE    BLOOD 


239 


*  LEUCOCYTES. 

:ion  according  to  structure 
behavior  towards  dyes. 

f    Mononuclear. 

I  Little  or  no 
ameboid  move- 


two  peripheral 
granules. 


I   I.  Small  lymphocytes  derived  from  adenoid  tissue.    Vary 
i  in  size  from  smaller  than  a  red  blood  corpuscle  to 

considerably  larger.  Mononuclear,  both  nucleus 
and  protoplasm  basophilic.  Outline  smooth  or 
irregular.  In  adults,  20  to  30  per  cent,  of  total  number 
of  leucocytes;  in  infants,  40  to  60  per  cent. 
Lari,^e  lymphocytes,  large  mononuclear  leucocytes, 
derived  from  bone  marrow  and  spleen.  Two  to  three 
times  the  size  ot  red  blood  corpuscle.  Large,  single 
nucleus;  both  nucleus  and  protoplasm  basophilic. 
Outline  irregular,  oval.  Surrounded  by  broad  zone 
of  protoplasm.  Form  from  4  to  8  per  cent,  of  total 
number. 

Polynuclear  nutrophilic  leucocytes. 

Polymorphonuclear      neutrophilic      leucocytes      or 

phagocytes.     About  same  size  as  No.  2.     Nucleus 

elongated,  twisted,  broken.    Granules  embedded  in 

protoplasm  stain  with  neutral  dyes   (neutruphilic). 

proper  stains  with  acid  dyes.    Most  com- 

.of  total 

nyelocyte 


P  o  1  >■  n  u  c  1  e 
p  o  1  y  m  o  r  p 
nuclear. 
P  h  a  g  o  c  >■  I 
active, ameL 
motion. 
Neutrop  hi 
basophilic,  1 
philic. 


Protoplasm 

mon  of  all  leucocytes.    62  to  70  per  cei 
cocytes.     Derived  from  neutropliilic 


(Ehrlich). 

4.  Polynuclear  oxyphilic  leucocytes,  same  as  No.  3,  except 

embedded  protoplasm  stains  with  acid  dyes,  or  eosin,. 
hence  also  called  polynuclear  eosinophilic  leuco- 
cytes. I  to  4  per  cent,  of  total  or  about  50  to  200  per 
c.  c.  of  blood. 

5.  Polynuclear    basophilic  leucocytes,    mast    cells,    size 

about  same  as  Nos,  3  and  4.  In  disease  size  may 
reach  22  micro-millimeters.  Embedded  grains  of 
protoplasm ,  different  sizes,  stain  only  with  basic  dyes. 
Nucleus  polymorphous.  Rare.  INJever  exceed  0.5 
per  cent. 

6.  Myelocytes.     Mononuclear  neutrophiles.  granular  cells 


I 


of  the  bone  marrow,  "  Intn 
rence,  border  cell  betwoLU 
loyic  conditions.  (Starvati' 
tions.)  Are  derived  from  1, 
develop  into  the  polvnuchai 
normally  found  in  the  circula 
with  dyes,  are  neutrophilii 
philic,  all  with  sinj^le,  larger 
protoplasm.    Diameters  lo-; 


,.     , I  occu. 

^^  -'.  -;;'    and  patho- 

'      ,■    HIS  into.xica- 

1  I  ■    \  tL's  (2)  and 

\  1'  -  '  3)  are  never 

I.  .According  to  action 
■osinophllic  or  baso- 
eus,  surrounded  with. 


The  protoplasm  of  normal  leucocytes  is  stained  uniformly  bright- 
yellow  by  iodine.  In  diseases  in  which  pus  is  a  product  of  the  disease, 
or  in  which  the  infection  or  intoxication  is  due  to  some  form  of  bac- 
terial invasion,  as  in  typhoid  fever  and  pneumonia,  the  granular  pro- 
toplasm is  stained  brown  by  the  reagent.  This  was  announced  a  few 
years  ago  by  Kaminer.  Later,  Wolff  announced  that  the  reaction  was 
due  to  the  presence  of  glycogen  and  occurred  irrespective  of  disease. 
Hirschberg  has  confirmed  Wolff's  work  and  the  staining  can  no  longer 
be  regarded  as  significant.  The  polymorphonuclear  neutrophiles  best 
show  the  reaction,  while  the  eosinophiles  are  exempt.  It  was  pre- 
viously taught  that  the  reaction  served  to  demonstrate  sepsis  and  alsO' 
to  distinguish  between  a  serous  and  a  purulent  effusion. 

The  number  of  leucocytes  per  cubic  millimetre  of  blood  varies 
much  both  in  health  and  disease.  The  average  may  be  stated  to  be 
5,000  to  6,000,  but  may  fall  anywhere  between  3,000  and  10,000 
within  strictly  physiologic  limits.    An  increase  above  normal  is  called. 


240  EXAMINATION    VF    THE    BLOOD 

liypei-lencocytosis,  or  simply  leiicocytosis :  a  diKiinuti&u  below  normal 
is  hypoleucoej'tosis.  The  increase  or  diminution  may  affect  all  the 
varieties  above  mentioned  but  more  generally  it  will  be  found  that  a 
particular  variety  suffers  much  out  of  proportion  to  the  remaining 
cells.  The  most  common  form  of  leucocytosis  is  an  increase  of  the 
polymorphonuclear  neutrophilic  cells  (3).  In  the  new-born  these 
exist  physiologically  to  as  high  as  20,000,  which  number  decreases  to 
10,000  by  the  end  of  the  first  year.  The  eosinophiles  may  reach  2,200 
(Taylor).  Pregnancy  and  labor,  severe  exercise,  bathing,  and  even 
digestion  increase  the  number  of  leucocj-tes  abo%'e  normal.  They  vary 
from  day  to  day,  and  from  day  to  night.  Such  variations  are  physio- 
logic and  temporary.  The  number  is  below  normal  in  the  ill-nour- 
ished, the  sickly  and  in  those  who  have  fasted.  If  a  deficient  amount 
of  food  has  been  eaten,  as  is  often  asserted  by  patients,  the  count  will 
verify  the  statement.  Such  conditions  of  ill-nourishment  and  unhy- 
gienic surroiindings  must  be  given  proper  weight  before  concluding 
that  a  count  of,  say,  3,000  is  pathologic. 

Cabot  gives  the  following  classes  of  pathologic  leucocytosis: 

Post  ha?morrhagic  leucocytosis. 

Inflammatory  leucocytosis. 

Toxic  leueocj'tosis. 

Leucoe>i;osis  in  malignant  disease. 

Leucocytosis  due  to  experimental  and  therapeutic  influences. 

Among  intiammatory  conditions  in  the  above  classification  are  in- 
cluded infectious  diseases. 

In  .septic  conditions  leucocytosis  increases  with  the  severity  of  the 
attack,  at  least,  so  long  as  resistance  is  normal.  Where  the  resistance  is 
greatl.v  diminished,  leucocytosis  diminishes  therewith,  and  may  fall  to 
a  low  point.    In  pneumonia,  its  absence  forebodes  a  fatal  termination. 

In  many  of  these  conditions,  while  the  neutrophiles  are  increased, 
the  eosinophiles  are  correspondingly  diminished. 

Leucocji;osis  is  absent  in  the  following  diseases:  T.vphoid  fever, 
malaria,  grip,  measles,  rotheln,  mumps,  cystitis,  all  forms  of  tubercu- 
losis and  tubercular  processes  except  the  meningeal  form. 

Bloodgood*  states  that  in  appendicitis  the  leiicocytosis  is  a  pretty 
safe  index  of  the  severity  and  extent  of  the  disea.se.  A  count  of  15,000 
falls  rapidly  to  10,000  with  the  amelioration  of  the  disease.    A  count 


'American  Medicine,  1901,  page  306-7. 


EXAMIXATION    OF    THE    BLOOD  241 

of  20,000  observed  within  forty-eight  hours  of  the  begmning  of  the 
attack  demands  operation.  In  gangrenoiis  eases  the  count  reached 
25,000  to  30,000.  Very  high  leucocytosis  observed  within  the  tirst 
forty-eight  hours  points  to  peritonitis. 

In  intestinal  obstruction  the  increase  is  of  especial  value,  rising 
rapidly  to  20,000  within  twenty-four  hours,  and  stiU  higher  in  gan- 
grene or  associated  peritonitis.  Later  in  the  disease  a  low  count  with 
persistence  of  the  symptoms  is  unfavorable. 

Fevers  with  leucocji;osis  are  not  typhoid,  since  it  does  not  occur 
in  uncomplicated  cases.  Its  occurrence,  therefore,  in  undoubted  cases 
poiuts  to  complications.  It  is  stated  that  in  articular  rheumatism 
compUeated  with  endocarditis,  the  count  does  not  rise  much  if  any 
above  that  for  the  uncomplicated  .joint  affection,  %-iz :  10,000  to  12,000, 


JS    ^"    a/  ^      O 


>-:SLlDe- 


Fig.  6i — The  Thoma-Zeiss  Counting  Chamber. 

but  that  when  complicated  with  pericarditis  the  average  rises  to  20.000 
or  over,  and  that  such  rise  foretells  the  complication. 

Tiibereulosis  is  only  attended  by  leucocji:osis  when  secondary  pus 
infection  occurs. 

The  eosinophiles  and  the  mast  cells  are  increased  in  myelogenous 
leuksemia,  while  in  the  hmiphatic  forms  of  the  disease  the  lymphocji;es 
are  increased,  numbering  40,000  to  200,000.  Increase  of  eosinophiles 
is  found  in  bronchitic  asthma,  in  scarlet  fever,  in  hydatid  disease  of 
the  liver,  as  noted  in  one  of  my  cases,  in  intestinal  parasites,  gon- 
orrhoea and  in  inflammatory  skin  disease. 

Blood  Counting.  The  most  suitable  apparatus  for  enumerating 
the  blood  corpuscles  is  the  cytometer  of  Thoma-Zeiss,  manufactured 
by  Zeiss.  It  consists  of  a  diluting  pipette  for  the  red  corpuscles, 
another  for  the  white,  a  specially  ground  cover-glass  and  a  counting 


242 


i:.\  AMI  NATION    (IF    THE    BI.OOD 


chtinihiT  ill  IIr'  liiittuni  uT  wliieh  is  placed  a  disc  ruled  into  squares 
whose  sides  measure  1-20  nini.  and  whoso  areas  are  therefore  1-400 
of  a  square  inillinietre.  The  depth  of  the  chamber  when  the  cover- 
glass  is  in  position  is  1-10  mm.  When  the  chamber  is  filled  the  con- 
tents overlyiui;'  each  square  will  be  a  column  1-400  nun.  base  by  1-10 
lum.  in  height  or  1-4000  cu.  mm. 

Hence  the  number  of  corpuscles  overlying  any  one  square  X  by 
4,000  would  equal  the  number  of  corpuscles  in  a  cubic  millimetre  of 
blood,  if  the  blood  examined  were  undiluted.  Since  it  is  impossible  to 
make  the  count  without  diluting  the  blood  to  100  or  200  times  its  own 
volume,  the  above  product  must  be  multiplied  by  the  dilution  mul- 
tiple.    Furthermore,  since  great  variations  occur  in  the  number  of 


Fig.    62 — Thoma-Zeiss    Hoemacytonieter    Pipette    nnd    Chamber. 

corpuscles  fouud  in  the  various  .squares,  in  practice  it  is  actually 
necessary  to  count  the  corpuscles  overlying  a  large  number  of  squai'es, 
divide  by  the  number  of  squares  counted  in  order  to  obtain  an  average, 
then  multiply  by  the  other  factors.  By  reason  of  the  ruling  presently 
to  be  described,  it  is  found  convenient  to  count  a  field  16X16  or  256 
squares.  Suppose  the  number  therein  totals  1,792,  giving  an  average 
of  7  for  each  .square,  the  dilution  being  200.  Then  7X4000X200= 
5,600,000  cells  per  cu.  mm.  of  blood.  Counting  chambers  with  the 
rulings  of  Turek  enable  the  enumeration  of  both  red  and  white  cells 
to  be  made  in  the  same  specimen.  In  this  apparatus  the  small  1-20 
umi.  .squares  are  fenced  off  into  blocks  of  4X4  or  16  of  the  smaller 
squares,  separated  by  interspaces  or  "alleys,"  the  width  of  the  small 
squares.     For  enumerating  the  red  di.scs,  the  16  cential  blocks  are 


EXAlIIIvATIOK    OF    THE    BLOOD  ■2-i3 

counted,  thus  giving  256  of  the  small  squares,  which  is  suiBcient  for 
a  fairly  accurate  average.  To  count  this  number  of  squares  after 
some  practice  requires  about  half  an  hoiir  and  the  result  is  generally 
between  1,200  and  1.500  corpuscles,  iluch  must  be  learned  by  prac- 
tice, and  accuracy  comes  only  with  experience.  After  ha^'ing  made- 
the  count  the  instrument  should  be  washed  with  water  and  the  whole 
process  repeated  with  a  second  drop  of  blood,  and  in  cases  of  wide- 
variation,  a  third  count  should  be  made. 

Enumeration  of  the  Bed  Blood  Corpuscles.  The  blood  is  most 
easily  obtained  from  the  eai--lobe,  which  may  be  fii'st  washed  with 
soap  and  water.  Disinfection  is  not  necessary.  Punctures  made  with 
a  three-sided  surgical  needle  furnish  a  free  flow  of  blood  and  obviate 
the  necessity  of  squeezing,  which  dilutes  the  drop.  Wipe  away  the 
first  drops,  then  draw  the  blood  directly  into  the  capillary  tube  of  the 
mixing  pipette  to  the  0.5  mark,  if  a  diliition  of  1 :200  is  desired,  or  to 
the  1.0  mark  for  a  1 :100  dilution.  In  eases  of  an£emia  the  latter  is 
preferable,  while  for  practice  upon  normal  Ijlood  the  former  suffices 
and  the  cells  are  more  quickly  counted,  with  less  strain  upon  the 
the  eyes.  Great  care  is  necessary  in  drawing  blood  into  the  tube  not 
to  pass  the  desired  mark.  In  case  such  accident  happens  the  pipette 
must  be  cleansed  immediately,  and  the  attempt  repeated.  The  mark 
reached,  the  blood  adherent  to  the  point  of  the  tube  is  carefully 
wiped  away  and  the  tube  ph-mged  directly  into  the  diluting  fluid 
which  is  di-awn  up  until  the  101  mark  above  the  bulb  is  reached.  The 
two  fluids  are  intimately  mixed  by  shaking  and  rotating.  The  portion 
which  has  remained  in  the  capillary  tube  and  not  mixed  must  be  ex- 
pelled, and  a  portion  of  the  remaining  fluid  transferred  to  the  count- 
ing chamber.  The  cover-glass  is  placed  over  it  and  the  slide  is  put 
on  the  horizontal  stage  of  the  microscope  where  it  should  be  allowed 
to  stand  for  several  minutes  in  order  that  the  corpuscles  may  settle 
evenly.  Much  care  and  practice  are  necessary  that  neither  too  much 
nor  too  little  of  the  fluid  be  placed  in  the  chamber.  If  too  miieh,  it 
will  overflow  into  the  rim  or  moat  which  siuTounds  the  graduated 
plate,  or  overflow  between  the  cell-rim  and  the  cover-glass.  If  too 
little,  the  count  will  be  inaccurate. 

If  the  drop  has  been  accurately  gauged.  Newton's  rings  will  ap- 
pear at  the  edge  of  the  cover-glass  as  far  as  it  rests  on  the  im deriving, 
cell  wall,  when  the  glass  has  been  pressed  into  place. 


244  EX  A. Ml  NATION    OF    THK    BLOOD 

Dilitliii;/  Fliiiils.  Tile  siiiijilcst  is  a  (t.8  111"!'  cent,  salt  solution,  or 
one  of  MfjSO^  ol'  ill)  per  cent,  strenstli.     (iowcis"  Hiiid  consists  of: 

Sodiiun  sulphate    gins.       6.3. 

Acetic  acid gms.       3.6. 

Distilled  water   gms.  117.0. 

'Poison's  tinid  is  convenient  as  it  stains  the  leucoc\i;es  and  faeili- 
tali's  their  enumeration.     Its  composition  is  as  follows: 

Sodium   chloride,    jturif 1.0       yin. 

Sodiiun  suli)hate,  puril' 8.0       ^m. 

Neutral  glycerine   30.0     c.  c. 

Methyl  violet,  oB 0.025  gm. 

Distilled   water    160.0      e.  c. 

Diluting  solutions  containing  mercuric  chloride,  as  Pacini's  and 
Hayem's,  are  advantageous  since  they  do  not  stain  the  tube  as  does 
Toison  's. 

Countituj  ilir  leucocytes.  The  same  chamber  is  used  for  count- 
ing the  white  cells  that  is  used  for  the  red  discs.  Turck's  ruling 
greatly  facilitates  the  work.  For  counting  the  white  cells  a  dilution  of 
1 :100  is  suiifieiently  accurate.  If  a  dilution  of  1 :200  has  been  used  for 
the  red" cells,  the  second  or  large  bore  pipette  may  be  used  for  this 
enumeration.  The  blood  being  drawn  np  to  the  1.0  mark,  Toison 's 
fluid  is  added  until  the  101  mark  is  reached,  when  the  steps  described 
in  the  case  of  the  red  corpuscles  are  repeated.  The  leucoc.ytes  are 
stained  bhie  by  the  fluid  and  the  corpiiscles  overlying  the  entire  set 
•of  large  blocks.  144  in  number,  are  counted,  beginning  at  one  corner, 
going  across  the  field  and  back  until  all  are  counted.  Corpuscles  lying 
in  the  interspaces  or  "alleys"  between  the  blocks  must  not  be  in- 
■eluded  in  the  count.  A  rule  of  procedure  must  be  adopted  in  regard 
to  counting  bodies  partially  within  and  partially  without  the  boun- 
daries. Perhaps  the  safest  plan  is  to  count  in  all  that  lie  on  two  ad- 
jacent sides  of  the  square  and  ignore  all  that  impinge  upon  the  two 
remaining  sides.  The  rule  is  equally  applicable  to  the  enumeration 
of  both  the  red  and  the  white  cells.  Divide  the  total  by  144  to  a.scertain 
the  average  for  one  square.  Since  these  blocks  are  composed  of  16 
small  blocks,  each  of  which  is  1-4000  cu.  mm.  in  contents,  it  follows 
that  one  of  these  columns  is  16-4000  cu.  mm.  or  1-250  eu.  nun.,  hence 


EXAMINATION    OF    THE    BLOOD  2-1:5 

multiplying  the  average  obtained  by  250,  by  the  degree  of  dilution 
100,  equals  the  number  of  leucocj'tes  per  cu.  mm.  in  the  blood  ex- 
amined. Thus,  if  65  leucoej^tes  are  counted  on  144  squares,  the 
average  per  square  is  0.45X25(3X100=11.250  leucocytes  in  one  cubic 
millimetre  of  blood.  This  method  has  the  advantage  of  being  much 
simpler  than  that  of  finding  the  cubic  contents  of  the  microscopic  field 
and  should  be  more  accurate. 

If  for  special  reasons  a  dilution  of  1 :10  or  1 :20  be  desirable,  it 
becomes  necessary  to  destroy  the  red  bodies,  since  their  preponderance 
would  obscure  the  white  cells.  In  this  case  a  0.5  per  cent  solution  of 
acetic  acid  to  which  has  been  added  a  little  gentian  or  methyl  violet, 
renders  the  red  cells  invisible  while  it  makes  prominent  the  leucocytes. 

The  apparatus  may  be  cleaned  by  first  washing  out  the  pipette 
with  the  diluting  fluid,  then  with  water,  afterwards  with  absolute 
alcohol,  lastly  with  ether.  The  counting  chamber  should  be  washed 
with  water  only  as  alcohol  and  ether  destroy  the  cement.  Explicit 
directions  usually  accompany  the  apparatus. 

A  magnifying  power  of  three  hundred  diameters  will  suffice  for  the 
count. 

The  ha?matocrit.  as  proposed  by  Blix  and  modified  by  Daland,  has 
the  advantages  of  celerity  and  ease  of  management.  It  consists  of  two 
graduated  glass  tubes,  50  mm.  long  and  0.5  mm.  in  diameter,  that  fit 
accurately  into  a  carrying  frame  which  revolves  in  the  ordinary  cen- 
trifuge. The  tubes  are  graduated  from  1  to  100.  The  blood  is  drawn 
directly  into  the  tube  from  the  puncture  by  means  of  a  rubber  tube, 
or  it  may  be  diluted  with  an  equal  volume  of  a  2.5  per  cent,  solution 
of  bi-chromate  of  pota.sh.  For  diluting,  the  pipette  of  the  Thoma- 
Zeiss  apparatus  may  be  used,  the  blood  being  drawn  to  the  1.0  mark, 
then  an  equal  quantity  of  the  diluent  drawn  in.  The  process  must 
be  repeated  some  four  times  in  order  to  obtain  sufficient  of  the  mixed 
fluid  to  fill  both  tubes  of  the  htematocrit,  to  which  it  may  be  directly 
transferred.  As  a  speed  of  10,000  revolvitions  per  minute  is  necessary 
for  good  results,  an  electric  current  is  desirable.  The  result  as  indi- 
cated by  the  scale  gives  the  number  of  corpuscles  per  cu.  mm.  by 
adding  five  cyphers  to  the  reading,  thus,  50  on  the  scale  indicates 
5,000,000  red  cells.  Doubling  the  scale  gives  the  volume  percentage 
of  corpuscles  to  the  normal ;  thus,  45  on  the  index  equals  90  per  cent. 
If  the  blood  has  been  diluted,  the  indicator  readings  must  be  multi- 
plied by  the  degree  of  dilution. 


24()  lOXA  Ml  NATION    (II'    TIIK    HI.OOD 

Much  criticism  has  ht'oii  bestowed  npou  the  results  of  I)ahmd"s 
method.  It  is  especially  claimed  that  it  is  inefScient  in  cases  in  which 
there  exists  much  A-ariation  in  the  size  of  the  corpuscles,  or  in  which 
the  leucocytes  are  considerably  increased;  but  Daland  claims  good  re- 
sults in  these  eases  as  well  as  in  the  others.  In  a  large  series  of  com- 
parative counts  made  with  both  the  ha?matocrit  and  the  Zeiss  instru- 
ment, I  obtained  quite  as  uniform  results  as  when  two  different  per- 
sons counted  the  corpuscles  in  separate  specimens  of  blood  from  the 
same  individual,  by  means  of  the  Zeiss  counter. 

Preparation  of  Dried  and  Stained  Films.  Wet  preparations  can 
be  utilized  only  when  the  microscope  and  pz'oper  materials  are  near 
at  hand.  When  the  examination  must  be  deferred  it  is  necessary  to 
make  use  of  dried  specimens.  They  are  prepared  by  pricking  the 
cleansed  finger  or  ear-lobe,  wiping  away  the  first  drops,  catching  the 
next  drop,  as  it  emerges  from  the  puncture,  upon  a  clean  cover-glass 
without  touching  the  glass  to  the  skin,  spreading  the  drop  into  a 
cajiillary  layer  by  covering  the  one  disc  witli  another  then  carefully 
sliding  them  apart,  and  drying  the  two  films  thus  obtained  in  the  air. 
The  dry  films  will  keep  indefinitely,  especially  if  placed  in  closed  jars. 

Simon  recommends  the  use  of  slides  instead  of  cover-glasses, 
spreading  the  drop  with  the  edge  of  a  second  slide  held  at  an  angle 
with  tlie  first.  The  superiority  of  his  method  rests  on  tlie  lessened 
difficulty  of  gauging  the  drop  to  the  size  of  the  cover-slip  and  the  more 
uniform  thickness  of  the  smear.  My  own  preference  is  to  bring  the 
edge  of  the  slip  even  with  the  edge  of  the  slide  and  to  catch  the  droji 
directly  in  the  capillary  space  thus  formed. 

Fixation  is  accomplished  by  exposing  the  specimen  to  a  tempera- 
ture of  140°  C'.  for  half  a  minute,  but  requires  special  apparatus. 
Lougei-  exposure  at  lower  temperatures,  as  one  hour  at  110°  will 
accomplish  the  same  end.  Fixation  by  immersion  in  a  mixture  of 
eipial  parts  of  absolute  alcohol  and  ether,  or  in  the  alcohol  alone,  is 
satisfactory  for  most  purposes.  For  the  first,  the  immersion  should 
last  from  one-half  to  one  hour:  for  the  second,  five  minutes  suffices. 

The  following  solution  is  more  satisfactoi-y  than  either  of  the 
above : 

Commercial  formalin.  40  per  cent 1  e.  c. 

Water    9  c.  e. 

Mix.   add   alcohol    SO  c.  c. 


EXAiriNATION    OF    THE    BLOOD  247 

Fix  by  covering  with  a  few  drops  of  tliis  solution,  allow  it  to 
remain  one  minute,  then  drain  off  and  immediately  replace  by  the 
staining  mixture  desired. 

With  practice  one  can  make  perfectly  satisfactory  stains  by  sim- 
ply passing  the  cover-glass  through  the  flame  about  twentj'  times  in 
rapid  succession,  learned  by  noting  the  effect  on  the  red  discs.  If  the 
heating  has  been  sufficient  they  will  be  stained  bright  yellow  by  the 
tri-acid  stain. 

Ehrlich's  tri-acid  stain  is  the  most  satisfactory  for  diagnostic  pur- 
poses and  is  all  that  is  necessary  for  the  clinician.  Gruber's  colors 
are  used.     The  dye  is  made  by  mixing  the  following: 

Saturated  watery  solutions  of  orange  G,  methyl  green  and  acid 
fuchsin  are  prepared  and  allowed  to  stand  for  several  days,  after 
which  the  clear  fluids  are  decanted.  The  dye  is  compounded  as 
follows : 

Orange  G.  sol 6  c.  c. 

Acid  fuehsin  sol -i  c.  c. 

Add  the  one  to  the  other  drop  by  drop,  while  shaking.  When 
thoroughly  incorporated  add 

]Methyl  green  sol 6  e.  c. 

Glycerine  5  c.  c. 

Absolute  alcohol 10  e.  e. 

Water 15  e.  c. 

Shake  well,  let  stand  for  twenty-four  hours. 

The  specimens  are  stained  with  the  above  compound  for  about 
five  minutes,  drained,  dried  with  bibulous  paper  and  examined  with 
the  one-twelfth  oil  immersion  lens,  with  the  wide  diaphragm. 

Ehrhch  's  triple  stain  dyes  the 

Eed  corpuscles,  orange  or  bright  yellow. 

Nuclei  of  leucocytes,  green. 

Nuclei  of  nucleated  red  cells,  green. 

Neutrophiles,  violet. 

Mast  cells,  imcolored. 

Eosinophiles,  red  or  copper-red. 

The  definition  of  the  nuclei  is  improved  by  counter-staining  with 


2-48  EXAMINATION    OP    TUE    BLOOD 

a  saturated  solution  of  methylene  blue.  After  washing  ott  tin-  triple 
stain  the  blue  solution  is  poured  over  the  film  and  washed  off  after 
one  or  iwo  seconds  (Hewes).  The  blue  eounter-stain  brings  out 
clearly  also  the  malarial  parasites,  whieli  do  not  show  in  tlie  Hhiis 
stained  only  with  the  triple  stain. 

Jenner's  stain,  the  eosinate  of  methylene  blue,  gives  satisfactory 
differential  pictures.  No  previous  fixing  is  necessary,  as  this  is  ac- 
complished by  the  methyl  alcohol  of  the  stain.  The  dye  consists  of  a 
0.5  per  cent,  solntion  of  the  powder  in  absolute  methyl  alcohol.  The 
films  are  well-covered  for  five  minutes,  washed  with  water,  dried  and 
examined. 

The  red  cells  are  stained  terra-cotta. 

Nuclei  of  both  red  cells  and  leucocytes,  blue. 

Neutrophiles,  purple-red. 

Eosinophils,  bright-red. 

Granules  of  mast  cells,  dark-violet. 

Ehrlich's  haimatoxylin-eosin  solution  is  also  known  as  GoUasch's 
dye.    It  is  frequently  used. 

Preparation :  Dissolve  2  gm.  ha?matoxylin  in  a  mixture  of  100 
c.  c.  each  of  alcohol,  glycerine  and  distilled  water.  Add  10  gm.  gla- 
■  cial  acetic  acid  and  a  slight  excess  of  alum.  The  solution  must  ripen 
for  four  to  six  weeks,  after  which  0.5  gm.  eosin,  or,  if  preferred, 
orange  G.,  is  added.  The  smears  are  fixed  either  by  heat  or  by  alcohol 
(five  minutes)  and  stained  for  varying  times  from  five  minutes  to 
two  hours,  according  to  the  intensity  desii-ed.  The  method  re(|uires 
less  skill  of  technique  than  either  of  the  others. 

The  nuclei  of  the  leueocj-tes  are  stained  dark-blue. 

Bodies  of  leucocytes,  light-blue. 

Red  corpuscles,  bright-red. 

Eosinophiles,  red-granular. 

Niiclei  of  normoblasts  and  megaloblasts,  dark-blue. 

Neutrophiles,  imstained. 

As  .said,  the  triple-stain  is  the  only  one  really  necessary  for  the 
practitioner,  and  familiarity  with  one  stain  and  the  ready  recogni- 
tion of  the  bodies  differentiated  by  it  is  far  more  useful  than  doubtful 
versatility  or  questionable  proficiency. 

Malarial  Organisms.  These  para.sites  are  readily  recognized  in 
wet  specimens  by  careful  focusing,  or  they  may  be  stained  for  per- 
manent preparations.     The  causative  factor  of  malaria  is  a  protozoon 


PHOfluClEHR  ^^^» 

Leucocyte 


RED  ceuLS 


SMftJ-L 

#i^k-.      ^  LYMPHOCYTES 


Q 


PLATE  XIX. 

CHRONIC  LYMPH/EMIA 
Small  Lymphocytes  in  various  stages  of  transition. 


EXAMINATION    OF    THE    BLOOD  249' 

of  the  class  which  grows  in  the  blood  and  is  therefore  called  hsema- 
tozoon.  This  particular  species  is  named  in  honor  of  its  discoverer, 
Plasmodium  nialarice  of  Lavaran.  The  most  common  form  of  the 
Plasmodium  is  found  enclosed  in  the  red  blood  corpuscle.  It  is  a  pale, 
segmented,  mulberry-like  body,  surrounding  a  mass  of  pigment.  If 
a  little  solution  of  gentian  violet  or  fuchsin  be  added  to  the  wet 
preparation,  the  stain  will  impart  itself  to  each  of  the  fifteen  or 
twenty  separate .  segments,  differentiating  a  deep-tinted,  central  nu- 
cleolus from  the  surrounding  protoplasm  of  lighter  stain.  Some  of 
these  same  bodies  may  be  found  apparently  free  from  the  corpuscle 
which  encapsulated  them.  The  free  bodies  may  be  entire  or  in  various 
stages  of  disintegration,  or  exist  as  small,  pale,  spherules  floating  free 
in  the  liquor  sanguinis,  or  attached  to  the  outside  of  the  red  corpuscle, 
where  they  exhibit  ameboid  movement.  Staining  here  shows 
also  a  central  nucleolus  and  a  nucleus. 

These  forms  are  found  previous  to,  or  during,  the  chill  and  dis- 
appear a  few  hours  after  that  event,  when  they  are  replaced  by  active 
ameboid,  inter-corpuscular  bodies,  constantly  changing  shape  and 
throwing  out  pseudopodia  into  the  substance  of  the  corpuscle.  These 
undergo  successive  changes,  until  the  pale  spherules  again  fill  the  cor- 
puscle, and,  at  the  time  of  the  next  chill  the  rosettes  and  radiating 
pigment  bodies  reappear.  The  crescents  which  are  found  in  the  blood 
associated  with  irregular  and  severe  cases,  according  to  Thayer  appear 
in  most  of  the  cases  of  Eestivo-autumnal  fever  during  the  second  and 
third  week.  The  crescent  develops  within  the  red  corpuscle  from  the 
small  hyaline  bodies  which  gradually  increase  in  size,  collect  pigment 
in  their  centers,  assume  a  crescentic  shape,  while  the  outline  of  the 
corpuscle  disappears.  The  last  to  disappear  is  a  line  connecting  the 
two  horns  of  the  crescent.  The  dried  preparations,  after  fixing,  are 
best  stained  by  the  eosinate  of  methylene  blue,  as  advised  by  Roman- 
owsky.    The  dye  may  be  purchased  ready  prepared. 

Hcemoglobin.  The  relative  values  of  the  hajmoglobin  to  the  cor- 
puscular elements  are  mentioned  in  the  discussion  of  the  various 
subjects.  It  is  to  be  noted  that  slight  alterations  in  the  amount  of 
hasmoglobin  are  constantly  occurring  as  the  result  of  diet,  weather 
and  habits.  It  is  influenced  by  age,  climate,  country,  sex  and  disease. 
The  hiemogiobin  reaches  its  lowest  value  in  chlorosis  where  as  low  as 
15  per  cent,  has  been  observed.  In  this  disease  the  fall  in  the  per- 
centage of  ht'emoglobin  is  below  the  fall  in  the  percentage  number  of 


"250  EXAMINATION    OF    THE    BLOOD 

the  red  eoi-puscles,  although  these  also  indicate  a  marked  decrease. 
The  corpuscles  look  pale.  In  Thayer's  series  the  average  for  the  red 
bodies  was  4,096,000,  while  the  percentage  of  hajmoglobin  for  the 
total  number  was  42  per  cent.  In  one  ease  the  corpuscles  were  85  per 
cent,  while  the  hEemoglobin  was  only  35  per  cent.  He  calls  attention 
to  the  fact  that  there  may  be,  liowever,  well  marked  actual  ana3mia. 

In  typhoid  fever  the  hirmoglobin  often  diminishes  more  rapidly 
than  the  corpuscles. 

In  septic  infections,  especially  in  general  septicemia,  the  same 
phenomena  may  be  observed,  but  generally  the  two  keep  pace  with 
each  other. 

Blood  cliangcs  in  peniicious  aiiainid.  In  progressive  pernicious 
anajmia,  the  corpuscular  loss  exceeds  the  loss  of  haemoglobin,  although 
the  latter  may  decrease  to  as  low  as  20  or  25  per  cent,  of  the  normal. 
The  ratio  is  important  as  a  diagnostic  feature.  A  fall  of  i-ed  corpus- 
cles to  half  a  million  is  not  uncommon  and  315,000  has  been  recorded 
by  F.  P.  Henry  (Anaamia,  Phila.,  1887).  Megalocytes  abound:  their 
diameter  ranging  from  10  to  15  micromillimeteis  as  compared  with  6.5 
to  9.5  for  normal  cells.  Microcytes  and  poikilocytes  are  also  abundant 
in  most  cases,  yet  none  of  these  features  ai'e  pathognomonic. 

Minute,  highly  colored  spherical  bodies,  known  as  Eiehhor.st's 
corpuscles  may  abound.  Eichhorst  regarded  them  as  pathognomonic, 
but  they  are  sometimes  absent. 

Two  kinds  of  nucleated  red  corpuscles  seen  in  pernicious  aniemia 
are  described  by  Ehrlich.  First,  small  normal  sized  corpuscles  with 
deeply  stained  nuclei.  Second,  large  forms  with  pale  nuclei  which  he 
calls  gigantoblasts.  Leucoej'tes  are  usually  slightly  diminished  in 
number,  although  the  mononuclear  white  cells  may  show  slight  in- 
crease. Henry  remarks  that  the  red  corpuscles  in  this  disease  re- 
semble the  blood  of  the  lower  animals  in  number,  shape  and  size,  and 
amount  of  haemoglobin. 

In  the  latter  stages  of  leuka-mia  the  same  ratio  as  the  above  is 
frequently  noted. 

Blood  changes  In  fjaslric  carcinoma.  In  carcinoma  of  Wv  stom- 
ach the  blood  changes  ofttimes  so  nearly  coincide  with  those  of  per- 
nicious anaemia  as  to  lead  to  eri-or. 

In  Osier's  series  the  average  of  corpuscles  in  59  cases  was 
3,700,000,  and  the  average  hemoglobin  in  the  same  series  was  45  per 
cent.     The  corpuscles  varied  between  1,000,000  and  6,000,000  while 


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PLATE  XX. 

PERNICIOUS  AN/EMIA. 


EXAMINATION    OF    THE    BLOOD  251 

the  hffimogiobin  only  fell  as  low  as  30  per  cent.  The  leucoej'tes  ex- 
ceeded 20,000  per  cu.  mm.  in  three  cases,  and  exceeded  12,000  per  cu. 
mm.  in  eighteen  eases. 

Blood  changes  in  leukcemia.  (a)  Spleno-medullary  form.  In 
^11  forms  of  leukaemia  the  diagnosis  must  be  made  by  the  examina- 
tion of  the  blood,  as  it  alone  offers  distinctive  featnres.  The  blood 
pictures  are  most  striking  and  significant.  In  the  commoner  form, 
the  lieno-myelogenic,  the  change  is  the  increase  in  colorless  corpuscles. 
The  normal  average  of  white  cells  per  cu.  mm.  of  blood  during  health 
has  been  stated.  Their  ratio  to  the  red  cells  is  set  down  as  1  to  500 
or  1  to  1,000.  In  leukemia  the  proportion  may  be  1  to  10  or  less. 
One  to  1  is  not  unknown.  The  eosinophils  maintain  their  proper  pro- 
portion to  the  other  white  cells,  hence  their  total  increase  is  very 
large  and  their  presence  in  the  stained  field  is  striking.  Their  sizes 
vary  greatly.  The  polynuclear  neutrophiles  may  maintain  normal 
proportions  early  in  the  disease,  but  frequentl.y  diminish  in  the  later 
stages.  The  greatest  increase  is  in  those  cells  not  normally  found  in 
the  blood,  the  myeloej-tes  of  Ehrlich.  They  are  marrow  cells  and  are 
much  larger  than  the  large  mononuclear  leucocytes,  from  which  they 
further  differ  by  having  their  protoplasms  filled  with  fine  neutro- 
philic granules.  (See  classification,  6a.)  Eosinophilic  myelocj^es  are 
also  plentiful.     (Classif.  6b.) 

Mast  cells  (polynuclear  cells  with  coai-se  basophilic  granules,  5b) 
are  always  present  in  considerable  number  and  may  be  even  more 
plentiful  than  the  eosinophiles  (Osier). 

Red  cells.  The  normal  red  cells  are  only  moderately  reduced  in 
spleno-medullary  leukremia,  seldom  falling  below  2,000,000,  but  nor- 
moblasts or  nucleated  red  cells  are  present,  some  with  large  pale 
nuclei,  some  showing  evidence  of  mitosis,  and  gigantoblasts  are 
present.  The  hemoglobin  value  is  usually  reduced.  Ameboid  move- 
ment is  feeble.  Charcot's  crystals  separate  out  from  the  leukemic 
blood  which  is  kept  for  a  short  time. 

(b)  Ljonphatic  Leukemia.  As  the  name  indicates  in  this  form 
the  principal  changes  occur  in  the  lymph  apparatus,  and  in  the  blood 
those  cells  which  are  derived  from  the  lymph  gland  predominate,  viz  -. 
Lymphocji;es.  The  proportion  of  colorless  cells  to  red  cells  is  less 
pronounced,  seldom  if  ever  reaching  1  to  10;  the  increase  consisting 
•almost  solely  of  lymphocjiies,  which  may  be  either  the  small  forms  or 
the  large  cell  h-mphocytes    (2-a)   which  approach  in  size  the  poly- 


252  EXA.MINATKIN    OK    TlIK    Bl.OOD 

nuclear  leucoctyes  (3-b).  In  the  |iurcl\-  lyiiiphiitic  i'orm  of  tlic  dis- 
ease, myelocytes  are  not  present  and  eosinophiles  and  nucleated  red 
corpuscles  are  rare,  but  in  the  mixed  forms,  which  occasionally  occur 
the  blood  picture  is  a  union  of  the  two  described. 

The  diagnosis  presents  only  one  difficulty;  to  distini;uisli  it  from 
ordinary  leucocytosis.  This,  however,  should  present  no  great  obstacle 
since  in  all  ordinary  leucocytoses  the  increase  takes  place  solely  in  the 
polynuclear  neutrophilic  cells  (3-b). 

Esfinialion  of  Ilamoglnbiii  in  Blood.  The  sini|)lest  iiiethod  of 
estimating  the  percentage  of  hb.  is  by  Tallcpiists's  color  scale.  (Noth- 
nagcl's  Ilandhuch.  Ehrlich  and  Lazarus.)  This  scale  is  a  series  of 
lithographed  tints  resembling  the  color  of  blood  containing  various 
percentages  of  hb.  ranging  by  tens  from  100  to  10.  The  blood-drop 
is  caught  on  a  piece  of  filter  paper  and  compared  directly  to  the  color 
scale  by  dayliaht.  Little  books  of  suitable  filter  paper  are  sold  with 
the  scale.  While  great  accuracy  is  not  attained  by  this  method  yet 
valuable  conclusions  may  be  drawn.  As  normal  blood  varies  between 
100  and  90  per  cent  it  cannot  be  said  that  a  decrease  below  the  nor- 
mal percentage  has  occurred  until  the  latter  degree  has  been  passed. 
Tallquist  noticed  that  in  stains  of  blood  taken  from  patients  suffer- 
ing H'ith  pernicious  anaemia  the  colored  center  was  surrounded  by  a 
zone  of  varying  width,  uncolored  in  some  cases,  or  colored  a  faint  yel- 
low. He  observed  the  same  thing  in  various  other  anemias  includ- 
ing chlorosis,  and  concludes  that  when  the  nimbus  is  entirely  uncol- 
ored. as  viewed  by  tran.sniitted  light,  the  corpuscles  have  fallen  to  one- 
half  the  normal  number  or  less,  and  that  the  greater  the  decimination, 
the  broader  the  zone. 

A  very  suitable  instrument  for  the  general  practitioner  for  esti- 
mating hb.  is  Gowers'  ha?moglobinometer,  to  be  recommended  by  rea- 
son of  its  low  cost  and  the  ease  with  which  it  may  be  used.  Results 
obtained  from  the  better  grades  of  this  instrument  will  probably  prove 
moi-e  reliable  and  accurate  to  the  general  worker  than  would  those  of 
the  more  complicated  instruments  of  Dare,  Oliver  or  von  Pleischl. 
which  are  better  suited  to  the  skilled  laboratory  technician  than  to 
the  needs  of  the  general  practitioner.  The  apparatus  consists  of  two 
small  tubes  of  equal  height  and  diameter,  which  stand  upi-ight  in  a 
wooden  base.  One  is  closed  and  contains  a  colored  solution  which  cor- 
responds in  color  to  a  1  per  cent,  solution  of  normal  blood  in  water. 
The  other,  open  at  the  top,  is  graduated  into  cu.  mm.  by  a  number 


ilBF      ^ 


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^ 


PLATE  XXI. 
LEUK/EMIA. 


EXAMrS'-VTIOX    OF    THE    BLOOD 


253 


scale.  A  lancet,  a  dropper  and  a  capillary  pipette  marked  at  20  eu. 
mm.,  with  suction  tube,  complete  the  apparatus.  A  few  di-ops  of 
water  are  placed  in  the  open  tube,  the  finger  is  punctured,  the  blood 
drawn  into  the  pipette  to  the  mark  and  immediately  discharged  into 
the  graduated  tube,  refilled  with  water  to  recover  all  remaining  blood, 
and  this  added  to  the  graduate.  The  tube  is  now  well-shaken  and  com- 
pared with  the  scale  by  standing  at  such  an  angle  that  the  edges  .join 
each  other  in  the  line  of  sight.  Water  is  added  little  by  little,  shaking 
the  tube  after  each  addition.  The  percentage  is  indicated  on  the  scale 
when  the  colors  exactly  correspond. 


A. 

Fig.  63 — Dares'  New  Haemoglobinometer  and  Colorimeter. 
Description. 

The  blood  pipette  is  shown  at  W.  Tt  consists  of  two  small  glass  plates,  one 
transparent,  one  white,  with  a  capillary  space  between,  into  which  the  blood  to  be 
examined  is  automatically  drawn,  undiluted.  The  plates  fit  into  the  detach- 
able clamp,  X,  and  are  held  evenly  in  position  by  the  thumbscrew.  After  filling 
the  capillar^-  tube,  the  clamp  and  tube  are  placed  in  clamp  holder,  white  glass 
outwards,  as  shown  in  the  drawing,  where  the}-  are  held  in  place  by  grooved 
guides  in  the  fixed  bracket. 

Fig.  A  shows  the  color  scale.  It  consists  of  a  prism  of  colored  glass,  E, 
a  semicircle  of  white  glass,  F.  on  the  edge,  H,  of  which  is  etched  the  percentage 
index  of  haemoglobin.  G  is  hole  or  hub  by  which  the  scale  is  fixed  in  case,  S, 
allowing  rotation.  I  is  a  white  glass  disc  which  ser\-es  as  background  for  the 
colors. 

Fig.  B  shows  instrument  ready  for  use  with  candle  illumination,  Y.  The 
color  scale  has  been  placed  in  the  metal  case,  S,  and  is  rotated  by  milled  wheel. 
R.  The  light  falls  equally  upon  the  exposed  white  glass  discs,  V  and  W.  The 
observer  views  them  through  the  detachable  camera  tube,  U.  T,  is  a  movable 
screen  to  shade  the  observer's  eye.  When  the  colors  exacth-  correspond,  the 
percentage  indicated  is  read  at  the  scale  opening,  Z.  Th  drawings  are  one-half 
actual  size. 


254  EXAMINATION  OF  THE  BLOOD 

Tlodgkin's  Disease.  The  blood  shows  littU>  that  is  characteristic 
apart  from  simple  ana?mia  of  varyinp:  irrades.  The  red  corpuscles  may 
sink  to  2,000,000.  Thej'  show  only  moderate  poikilocytosis.  The  white 
corpuscles  may  show  a  moderate  increase,  with  abundant  lymphocytes. 
Occasionally  the  white  cells  increase  inordinately  and  resemb!-3  the 
characters  found  in  lymphatic  leukajmia. 

Purpura.  The  blood  changes  are  those  of  anivinia  with  ihr  hh. 
line  below  the  corpuscular  line. 

Addison's  Disca.ie.  Anasraia  is  ;jrenerally  present  aei-ording  to 
Addison,  but  sometimes  is  wantinu-.  In  AVilson"s  ease  the  lilood  re- 
sembled pernicious  anaemia. 

Splenic  Ananiia.  This  is  described  as  a  profound  anu'inia  wiili- 
out  leucocj'tosis,  and  often  without  marked  poikilocytosis. 

Pulmonary  Tuberculosis.  References  to  the  blood  changes  ar-e 
included  in  the  general  description  of  the  malady.  Recent  investi- 
gations by  UUom  and  Craig  show  that  when  a  cavity  is  present  there 
is  a  constant  mild  auajmia,  associated  with  a  decrease  of  the  hemo- 
globin. They  find  that  an  increase  of  the  er^-throcytes  in  cases  with- 
out cavity  is  a  favorable  symptom.  A  decrease  of  leucocytes  in  ad- 
vanced cases  is  unfavorable.  They  regard  an  actual  increase  of 
lymphocj'tes  as  indicating  an  increase  in  the  i-esistanee  on  the  part 
of  the  organism  against  the  tuberculous  infection,  hence  such  increase 
as  well  as  augmentation  of  the  transitional  forms,  is  to  be  regarded 
as  favorable. 


SECTION  XIII. 

DISEASES  OF  THE  ABDOMEN, 

The  abdominal  cavity  contains  many  and  varied  organs  whose- 
physiologic  otfices.  while  they  differ  exceedingly  are  yet  closely  re- 
lated  to  one  another  in  that  they  contribute  to  a  common  end.  Yet 
in  spite  of  this  relationship  it  may  be  said  that  disease  of  one  or  the 
other,  whatever  may  be  its  nature,  gives  rise  to  no  symptom-group  or 
correlated  phenomena  in  any  way  comparable  to  those  associated  with 
disease  above  the  diaphragm.  Secretion  or  excretion  may  be  altered, 
function  maj-  be  changed  or  even  abrogated  as  the  result  of  disease, 
yet  inter-dependent  symptoms  and  inferential  physical  signs  are  not 
a  consequence.  Pei'haps  the  one  exception  to  this  statement  is  that 
changes  in  the  blood  are  apt  to  be  associated  with  alteration  and  dis- 
ease of  each  of  these  organs. 

For  these  reasons  physical  exploration  of  the  abdomen  presents 
many  more  difficulties  and  yields  less  fruitful  and  less  satisfactory 
results  than  when  the  same  methods  are  applied  to  the  thoracic  organs. 
Nor  is  the  reason  therefor  far  to  seek.  The  abdominal  organs  are 
many,  the  thoracic  few;  the  abdominal  organs  are  packed  in  a  loose 
ca^aty  with  distensible  walls,  and  their  size  constantly  changes  with 
their  functions.  The  thoracic  walls  are  almost  unyielding  the  posi- 
tion of  the  organs  is  fixed  and  their  capacity  but  little  changed  even 
in  severe  disease.  The  contents  of  the  abdominal  organs  may  be  solids, 
liquids  or  gases,  or  an  admixture  of  all  of  these ;  some  may  be  greatly 
distended  or  totally  collapsed,  as  the  stomach,  intestines,  lu-inary 
bladder,  gall  bladder  and  uterus:  while  heart  and  lungs  are  subject  to 
but  little  variation.  Lastly  the  action  of  the  thorax  and  its  organs  is 
regular  and  rhythmical :  that  of  the  abdomen  and  its  \dscera  irregular 
and  intermittent. 

The  same  methods  are  used  which  we  have  seen  applied  to  the 
thorax  but  their  relative  importance  changes.  Inspection  and  palpa- 
tion yield  most  valuable  information  here,  while  auscultation,  the  most 
important  in  thoracic  exploration,  is  of  relatively  little  importance- 


Jol>  DISEASES  OK  THE  ABDOMEN 

when  applied  to  the  abdomen.  Tlie  most  favorable  position  for  ex- 
amination of  the  abdomen  is  in  many  eases  the  erect  posture,  althousih 
recumbency  is  often  necessitated  by  the  form  of  sickness,  or  in  order 
to  seciu-e  complete  relaxation.  The  knee-breast  or  knee-elbow  posi- 
tions furnishes  most  information  in  cases  of  movable  organs,  tumors 
and  dropsies.  Not  only  should  the  front,  but  also  the  sides  and  the 
back,  be  examined.  Relaxation  is  secured  by  elevating  the  shoulders 
and^  gently  flexing  the  thighs.  Anjesthesia  must  sometimes  be  re- 
sorted to. 

Anatomy.  Whether  the  segmentation  of  the  abdomen  into  nine 
areas  has  survived  the  test  of  time  because  it  is  of  practical  value,  or 
whether  it  is  due  to  innate  conservatism  is  questionable.  Certain  it  is 
that  the  di%'isions  are  based  neither  on  substantial  anatomic  gi-ounds 
nor  warranted  by  convenience.  Variations  in  the  descriptions  as  found 
in  existing  text-books  are  innumerable  and  the  hope  of  uniformity  is 
remote.  Anderson's  suggestion  that  the  boundary  lines  be  converted 
into  planes,  defined  on  the  dorsal  as  well  as  on  the  ventral  surfaces  is 
here  adopted.  The  plan,  however,  was  originally  suggested  many 
years  ago  by  Dr.  Bright.  The  abdominal  organs  vary  widely  in  their 
positions  within  physiologic  limits,  hence  their  positions  and  relations 
can  be  described  only  with  approximate  correctness. 

Two  horizontal  planes  are  passed  through  the  abdomen,  the  upper 
at  the  lowest  point  of  the  tenth  costal  cartilage.  This  plane  lies  about 
two  inches  above  the  umbilicus,  marks  the  lowest  anterior  point  of  the 
costal  border  and  cuts  the  second  lumbar  vertebra  posteriorly.  It  cuts 
through  the  transverse  colon,  the  stomach,  a.seending  and  descending 
colon,  the  lower  curvature  of  the  duodenum,  the  small  intestines  and 
the  kidneys. 

The  second  plane  passes  horizontally  backward  through  the  an- 
terior superior  iliac  spines  into  the  pehns. 

A  third  plane  carried  across  the  true  pelvis  at  the  upper  level  of 
the  s\"mphysis  cuts  the  distended  bladder,  the  fundus  uteri,  the  ova- 
ries and  Fallopian  tubes,  the  small  intestines,  the  Cfecum  or  lower 
part  of  the  ascending  colon,  the  sigmoid  flexure  and  the  upper  end  of 
the  rectum. 

For  the  longitudinal  planes  as  pointed  out  by  Andei'son  the  outer 
borders  of  the  recti  muscles- — extending  from  the  infra-costal  furrow 
above  to  the  spine  of  the  pubis  below — have  the  advantage  of  easy 
location   and  of  gi^ang  much  gi-eater  sj-mmetry  to  the   regions   de- 


DISEASES  OF  THE  ABjSOMEN 


257 


)' 


Fig.  64 — The  abdominal  organs  viewed  from  behind.     The  diaphragm  partly  re- 
moved.    From  Cunningham's  Anatomy,  by  permission  of  Wm.  Wood  &  Co. 


DISEASES  OF  THE  ABDOMEN  259 

limited,  than  the  old  vertical  lines  bisecting  Ponparfs  ligaments. 
The  rectal  lines,  furthermore,  bring  the  inguinal  region  entirely  into 
one  division.  The  vertical  planes  cut  the  transverse  colon,  the  small 
intestine  and  kidneys.  The  ovaries  lie  at  the  intersection  with  the 
pubic  plane.  Further,  the  right  plane  cuts  the  sail  bladder,  the 
ciecum ;  the  left  cuts  the  stomach,  the  pancreas,  the  spleen  and  the 
sigmoid  flexure. 

METHODS  OP  EXAMINATION. 

Inspection.  The  shape  of  the  ideal  abdomen  is  flatly  elliptical 
with  a  slight  depression  marking  the  umbilicus,  a  shallow  central 
groove  and  two  vertical  lines  delineating  the  inner  and  outer  edges 
of  the  recti  muscles,  and  three  transverse  lines  marking  tlie  muscle 


Fig.  65 — A  convenient  position  for  palpation  of  the  abdominal  organs,  which 
may  be  used  in  home  or  office.  Especially  useful  in  searching  for  small- 
growths  of  pylorus. 

into  zones.  It  is  seldom  seen  except  in  well-developed,  muscular  young 
men.  I  have  never  observed  the  transverse  lines  in  women.  They  are> 
absent  in  the  very  young  and  those  past  fifty  years. 

The  size  and  shape  of  the  abdomen  vary  greatly  in  health  and: 
its  appearance  is  measurably  modified  by  certain  physiologic  condi- 
tions. The  abdomen  of  the  child  is  considerably  larger  in  proportion 
to  the  size  of  the  chest  than  is  that  of  the  adult.  Again  in  old  age 
the  abdomen  is  apt  to  increase  in  its  volume  while  the  thorax  shrinks, 
thus  renewing  the  disproportion.  It  is  more  apt  to  become  voluminous 
with  advancing  years  in  women  than  in  men,  and  repeated  preg- 
nancies leave  an  indelible  stamp.  A  full  meal  distends  its  upper- 
portion. 


261)  DISEASES  OV  THE  ABDOMEN 

l'i-(il);ilily  as  an  inherited  tpnck'ncy  the  waist  eireiinil'ereiice  varies 
moiv  ill  women  than  iu  men.  Its  disproportion  to  the  girth  of  tlie 
thorax  is  greater,  and  iu  the  higher  orders  of  society  where  lacing  has 
been  longer  and  more  strenuously  practised  the  eA'ects  are  much  more 
mai  ked  than  in  the  lower  orders,  a.s  evinced  by  our  immigrants.  It 
tends  to  displace  the  liver  and  the  free  end  of  the  .stomach  downward, 
as  well  as  to  unduly  contract  the  lower  ribs  which  are  greatly  iii- 
crea.sed  in  their  inclination,  lessening  the  costal  angle  and  dinnni'^hing 
the  lower  intercostal  spaces. 

The  pelvic  portion  of  the  abdomen  is  proportionail\-  idnger  in 
women  and  the  distance  from  the  xyphoid  cartilage  to  (he  symphysis 
pubis  varies  more  than  in  men,  thus  giving  the  female  more  "waist" 
and  less  chest  length.  We  note  the  size  and  shape  of  the  abdomen 
and  observe  its  movements,  and  look  for  changes  which  may  result 
from  such  alterations.  Alterations  in  the  shape  of  the  abdomen  due 
to  disease  consist  in  enlargements  or  retractions  of  its  walls. 

Enlargements  of  the  abdomen  may  be  general  and  symmetrieal, 
or  local  and  irregulai'.  General  enlargements  are  caused  by  accumu- 
lations of  gas  within  the  .intestinal  canal,  particularly  within  the 
colon  (tympanites)  as  occurs  in  typhoid  fever:  by  fluid  aeenmnla- 
tions  within  the  peritoneal  cavity  (ascites)  or  in  the  parietal  tissues 
(cedema  >  -.  \>y  tumors  or  new-growths,  in  which  ease  the  enlargement 
may  be  local  or  general. 

Tjoeal  enlargements  are  in  the  main  due  to  hypertrophy  of  some 
special  organ  as  the  liver,  the  spleen,  the  kidney  or  the  ovary,  to 
hernias  or  rarely  to  enlargements  of  the  mesenteric  glands,  or  accumu- 
lations of  fiBces.  Local  inflammations  such  as  appendicitis  often  show 
local  swelling.  The  descent  of  the  diaphragm  and  the  bulging  in  the 
epigastrium  due  to  fluids  in  the  thoracic  cavity  has  been  mentioned. 

Retraction  of  the  walls  is  seen  in  all  forms  of  acute  febi'ile  and 
w-asting  diseases  as  typhoid  fever,  tuberculosis  and  cancer.  It  occurs 
and  is  progressive  in  intestinal  strictures  and  in  stenosis  of  the  gastric 
orifices.  Infective  and  catarrhal  diseases  of  the  bowels  accompanied 
by  diarrhoea,  tuberculosis,  meningitis  and  some  other  cerebral  diseases 
rapidly  produce  it.    It  is  extreme  in  lead  colic. 

Alterations  in  the  movements  of  the  abdomen  indicate  change  in 
the  respiratory  rhythm  or  in  the  peristalsis.  In  the  unrestricted 
belly  the  walls  rise  and  fall  with  the  excursions  of  the  diaphragm.  In 
disease  they  may  increase  with  the  latter  or  vice  versa.    Thus  in  supra- 


PLATE  XXII. 
ANTERIOR  SURFACE  TOPOGRAPHY  AND  REGIONAL  LINES. 


A.   Aorta. 

LV.  Left  Ventricle. 
RV.  Right  Ventricle. 
P.  Pulmonary    valve. 


A'   Aortic    valve. 
M.   Mitral    valve. 
T.   Tricuspid  valve. 
G.  Bl.  Gall  Bladder. 


DISEASES  OF  THE  .VBDOJIEjSI 


261 


diapliragmatie  inflammation,  as  pleurisy  and  pericarditis,  the  muscles 
are  increased  in  their  play,  while  in  inflammations  below  the  partition, 
as  peritonitis  or  intra-peritoneal  growths  or  colic,  their  movements  are 
held  in  abeyance  and  the  costal  type  of  respiration  prevails.  In 
thin-walled  individuals  the  outlines  of  some  of  the  organs  and  the 
movements  of  peristalsis  are  frequently  apparent,  and  with  the  loss 
of  adipose  in  the  course  of  wasting  diseases  they  become  so.  Semi- 
rhythmical  contractions  and  relaxations  of  the  abdominal  muscles  are 
not  unusual,  especially  in  the  sick,  and  the  shifting  of  gaseous  accumu- 
lation, accompanied  by  noise,  is  a  common  event.  The  great  curvature 
of  a  well-inflated  stomach  may  be  easily  traced. 

We  examine  the  state  of  the  skin,  whether  soft,  rough  or  smooth : 
moist  or  dry  and  branny.  Its  color,  whether  it  indicates  jaundice  or 
impeded  circulation.  We  note  distention  of  veins  and  capillaries,  es- 
pecially in  the  umbilical  zone  already  described,  and  the  frequently 
transmitted  epigastric  pulsation  which  is  sometimes  mistaken  for 
aneurysm. 

Palpation.  In  order  to  secure  the  best  results  from  palpation, 
the  complete  relaxation  of  the  parietal  walls  is  necessary.  To  accom- 
plish this,  place  the  patient  upon  a  hard  mattress  with  the  legs  and 
thighs  partially  flexed.  It  is  necessary  to  change  the  position  from 
the  back  to  the  side,  or  to  the  knee-breast  posture  in  detecting  the 
presence  of  fluids,  movable  tumors  or  fluctuation. 

The  hand  should  be  well-warmed  so  as  not  to  cause  involuntary 
.shrinking  and  contraction.  The  side  of  the  hand  or  the  tips  of  all 
the  fingers  used  together  is  preferable  to  the  single  finger.  Punching 
and  poking  are  to  be  avoided.  The  pressure  must  vary  with  the  end 
sought :  slight,  forcible,  continuous  or  interrupted,  being  singly  or 
alternately  used :  care  being  exercised  not  to  cause  useless  pain  by 
Tinnecessary  repetition. 

Note  whether  the  skin  is  hot,  indicating  fever  or  inflammation, 
or  cold,  indicating  chill  or  deficient  circulation :  whether  the  tissues 
are  unusually  relaxed  or  resisting  and  elastic  and  whether  any  redema 
exists. 

The  examination  of  the  contained  organs  determines  their  size 
and  position,  whether  fixed  or  movable  and  whether  pulsation  is 
present ;  their  consistency  and  outline,  whether  smooth,  nochilar.  tense, 
tender,  softened  or  hardened. 


I'(i2  DISEASE.-?  OF  THE  .\hD.)Mi:N 

Fremitus  chu'  to  enlarued  spli'i'u  or  liver  may  nci'asionally  he- 
detected. 

Fluctuation  means  the  presence  of  lluid.  in  oi'dcr  to  dotcut  il 
the  examiner  places  cue  hand  at  the  distal  part  of  the  collection,  and 
taps  upou  the  overlying  surface.  The  peculiar  stroke  communicated 
to  the  hand  hy  the  Huid  set  into  vibration  is  called  fluctuation.  Cir- 
funiscribed  Huctuation  is  distinguished  from  fl\ictuation  due  to  Huids 
free  in  the  cavity  by  its  area  and  position  and  by  not  gravitating 
freely  with  changes  in  the  postui-e  of  the  patient.  Such  collections 
occur  in  ovarian  cysts,  ligamentous  cysts,  hydatids  of  tlir  livri'  ami 
pos.sibly  in  cystic  kidney.  Encysted  collections  of  pus  or  other  tluidsi 
limited  by  peritoneal  adhesions,  fluids  distending  the  fallopian  tubes, 
and  ab-scess  of  the  abdominal  walls,  may  also  give  I'ise  to  Incalizeil 
fluctuation. 

Pain  may  be  superficial  or  deep  and  the  amount  and  kind  oi' 
pressure  necessary  to  produce  it  determine  this  fact.  The  character 
of  the  pain  and  the  manner  in  which  it  is  influenced  by  palpation 
have  no  little  significance.  Pains  due  to  inflammation  of  the  bowels 
or  other  mucous  membranes  are  dull,  heavy  and  continuous  and 
require  considerable  pressure  to  manifest  them.  Pain  arising  from 
inflammation  of  the  serous  coverings,  the  peritoneum,  is  sharp  and. 
cutting,  subject  to  exacerbations  and  increased  by  slight  pressure. 
Colicky  pains,  nerve  pains  or  neuralgias  are  often  relieved  by  firm 
pi-essure.  although  a  touch  may  cause  a  painful  spasm,  which  distin- 
guishes them  from  the  tenderness  resulting  from  iuflammatorx' 
troubles. 

Palpation  includes  vaginal  and  rectal  examinations,  for  fullei- 
details  upon  which  subjects  the  reader  is  referred  to  special  works. 

Percussion.  By  percussion  we  determine  the  size  and  position  of 
the  various  organs,  their  relations  to  each  other  and  even  gain  consid- 
erable information  as  to  their  contents,  since  the  note  varies  unmis- 
takal)ly  therewith.  The  position  of  the  patient  best  suited  for  per- 
cussion is  recumbency  upon  the  back,  as  for  palpation.  The  fingers 
furni.sh  the  best  plexor  and  pleximeter,  and  the  variations  in  the 
note  elicited  are  so  manifest  and  so  readily  recognized  that  the  student 
will  do  well  to  familiarize  himself  with  their  qualities  before  essaying 
thoracic  adventures.  These  notes  are  dull,  flat  and  tympanitic  ac- 
cording to  the  point  chosen  and  the  organ  percussed.  The  body  of 
the  liver,  the  spleen  and  the  kidiieys  give  forth  a  perfectly  flat  note. 


DISEASES  OF  THE  ABDOMEN  263 

while  their  edges  which  overlap  the  stomach,  colon  or  intestines  give 
a  varying  dull  note.  The  small  intestines,  the  colon  and  the  stomach 
give  a  full  tympanitic  note,  which  may  be  characterized  as  small, 
medium  and  large  for  the  three  viscera  in  the  order  named.  The 
separation  of  the  three  organs  nevertheless  requires  considerable  deli- 
cacy of  discrimination,  by  reason  of  the  variations  of  the  note  which 
arise  from  different  conditions  of  these  viscera.  Thus,  each  may  be 
distended  to  its  fullest  capacity  by  gaseous  or  solid  contents,  or  may  be 
in  a  state  of  collapse,  or  they  may  be  partly  filled.  In  each  condition 
the  note  for  the  same  organ  will  differ.  The  quality  of  the  note  varies 
but  little,  being  tympanitic  in  all  cases  except  when  the  viscus  is 
filled  with  solid  matter,  but  the  pitch  varies  widely.  As  stated  in  our 
preliminary  considerations,  pitch  rises  with  the  tension  but  diminishes 
as  the  enclosed  air  volume  increases,  provided  the  tension  remains 
ilie  same. 

From  the  foregoing  it  will  be  seen  that  the  note  of  large  tympany, 
or  stomach  tympany  gotten  by  percussing  a  moderately  distended 
stomach  which  is  normally  the  lowest  pitched  sound  obtainable  from 
the  human  body,  rises  in  pitch  if  the  gas  so  distends  the  stomach  as 
to  increase  its  tension,  when  the  note  may  become  metallic  or  amphoric. 

The  intestines,  being  smaller  cavities,  give  a  higher  pitched  note 
than  the  stomach;  the  tension  being  equal,  this  note  is  higher  for  the 
small  intestine  than  for  the  colon. 

Increase  in  size  of  the  solid  organs,  as  well  as  new  solid  growths, 
are  recognizable  by  the  extension  of  their  area  of  flatness;  thus,  en- 
larged liver,  kidneys,  spleen,  uterus,  tumors  of  ovary,  womb  or 
mesenteric  glands  or  aneurysm  of  the  great  vessel  may  be  recognized 
and  their  limits  determined.  A  full  bladder  gives  us  an  area  of 
dullness  above  the  symphysis,  where  intestinal  tympanj^  replaces  it 
when  emptied.  So  too,  distentions  of  the  hollow  viscera  manifest 
themselves  by  a  change  in  the  percussion  note,  the  tympany  increasing 
with  the  distention. 

It  will  thus  be  seen  that  intelligent  percussion  furnishes  valuable 
results.  In  order  to  obtain  the  full  benefits  the  areas  must  be  care- 
fully gone  over  from  side  to  side  and  from  above  downward  with  a 
stroke  of  varying  strength ;  now  light,  to  elicit  superficial  resonance ; 
now  medium,  to  determine  relative  dullness;  and  strong,  to  demon- 
strate deep-seated,  covered-in  flatness. 


2()4  DISEASES  OK  THE  ABDOMEN 

The  percussion  areas  of  the  various  or^'ans  will  he  liiveu  iu  detail 
along  with  the  consideration  of  their  diseases. 

The  state  of  the  abdominal  walls  may  interfere  witli  the  satis- 
factory examination  of  the  organs:  thus  accunuilation  of  fat  seriously 
intiuenees  palpation  and  the  percussion  note.  Conti-action  and  spasm 
of  the  parietal  uuiscles,  as  occurs  in  beginning  peritonitis,  or  the  uni- 
iati'ral  contraction  of  the  rectus  as  seen  in  appendicitis,  may  retard 
the  examination  yet  contribute  to  its  diagnosis.  (Edema  of  the  walls, 
such  as  occurs  in  chronic  Bright 's  disease,  seriously  interferes  with 
the  examination. 

Auscultation.  Over  the  abdominal  tract  no  sounds  arc  heard  iu 
health  save  the  whirr  of  the  blood  through  the  aorta,  the  shifting  of 
gas  in  the  intestines  known  as  "borborygmi"  and  certain  churning 
sounds  of  a  somewhat  metallic  character  which  arise  from  tht'  mixed 
contents,  solids,  liquids  and  gases,  of  the  stomach. 

In  disease  the  bruit  of  an  aneurysm  may  be  present.  A  fi'iction 
fi-emitus  due  to  two  inflamed  surfaces  of  peritoneum  rubbing  togethei' 
is  much  rarer  than  friction  sounds  in  the  region  above.  A  blovvinir 
thrill  or  murmur  is  sometimes  heard  over  the  spleen  when  that  organ 
is  enlarged. 

The  placental  bruit  and  the  sounds  of  the  foilal  heart  Ix^long 
more  properly  to  the  tield  of  obstetrics,  but  are  pathognomonic  of 
the  pregnant  state. 

DISEASES  OF  THE  PERITONEUM. 

The  peritoneum  lines  the  entire  abdominal  cavity  and  .s  .so  re- 
flected as  to  enclose  wholly  or  partly  all  the  contained  visceia,  vessels 
and  structures. 

PERITONITIS.      INFLAMMATIOxX     OF    THE    PERITONEUM. 

Clafisificafion:  Acute,  chronic:  primary,  secondary:  local,  gen- 
eral :  simple,  septic. 

Morbid  varieties:     Fibrinous,  serous,  purulent. 

Symptoms:  Pain;  severe,  cutting,  piei'cing,  griping.  In  puei'- 
peral  cases  less  severe.  Tenderness.  Seat  of  pain  and  seat  of  tender- 
ness may  not  coincide.  Chill;  vomiting,  early  and  severe.  Vomited 
matter;  food,  bile  and  even  faeces. 

Fever:    Generally  101°  to  103°;  evening  rise. 

Pulse:    Rapid,  increases  with  disease,  130  to  140. 


DISEASES  OF  THE  /VBDOMEN 


26^ 


Respirations:  Superficial,  painful,  shallow.  May  be  30  to  40' 
per  minute. 

Physical  signs:  Patient  lies  on  the  back  with  the  knees  flexed. 
Abdominal  walls  at  first  tense  and  retracted,  resistant.  Diminution 
or  suppression  of  abdominal  breathing;  thoracic  breathing  increased. 
Later  abdomen  swells  and  becomes  tympanitic,  resistance  passes. 

Disappearance  of  liver  dullness  points  to  presence  of  gas  free- 
in  the  peritoneal  cavity,  but  previous  adhesions  may  hold  the  liver 
against  the  parietal  wall  or  a  coil  of  distended  intestine  may  inter- 
vene and  replace  the  dullness.  Pain  is  manifest  on  slight  touch,  but. 
actual  seat  of  tenderness  is  only  determined  by  firm  pressure.  Fluid, 
indicated  by  fluctuation,  gravitates  into  the  cavity  while  the  intestines, 
float  on  top.  Dull  area  shifts  with  the  changes  of  position.  Hiccough 
may  indicate  involvement  of  the  diaphragm  covering.  Friction  or 
crepitation  is  often  heard.  Heart  is  displaced  upwards  or  outwards, 
apex  may  be  in  the  fourth  interspace  and  heart  and  liver  dullness  be 
found  in  the  third  interspace. 

Urine  scanty,  dark,  heavy,  contains  albumin  and  indican  in  large 
quantity.  Simple  test:  Shake  together  equal  parts  of  HCl  and 
urine,  then  add  three  drops  of  a  freshly-made,  saturated  solution  of 
chlorinated  lime.  Indican  is  indicated  by  the  dark  blue  color  which 
immediately  succeeds. 

In  the  chronic  variety  the  chief  manifestation  is  a  collection  of 
fliiid  in  the  peritoneal  cavity.  The  collection  occurs  independently  of 
tuberculosis,  cancer  and  causes  of  ascites. 

THE  STOMACH. 

When  the  stomach  is  empty,  or  not  distended  with  gas,  its  out- 
line and  position  are  not  indicated  by  any  prominences  on  the  outer 
wall,  and  palpation  as  well  as  inspection  fails  to  furnish  any  informa- 
tion as  to  its  location.  Since,  however,  the  viscus  is  seldom  if  ever  in 
a  state  of  collapse,  percussion  gives  us  a  tympanitic  resonance  so 
distinctive  and  drum-like  as  to  enable  us  to  differentiate  it  from  the 
neighboring  organs.  The  flatness  of  the  percussion  note  which  marks 
the  liver  area  limits  the  stomach  above  and  easily  determines  its 
upper  boundary.  The  inner  border  of  the  spleen  limits  the  fundus  on 
the  left.  The  degree  of  obliquity  of  the  stomach  is  still  a  matter  of 
dispute,  the  merits  of  which  we  will  ignore,  at  present,  stating  what 
we  consider  the  most  accurate  views.    When  the  stomach  is  distended 


-26G 


DISEASES  OF  THE  ABDOMEN 


the  t'uiulus  aud  greater  curvature  rotate  to  the  front,  and  eome  in 
immediate  contact  with  the  abdominal  wall.  This  portion  is  trian- 
yriilar  in  shape,  bounded  on  the  right  and  above  by  the  liver,  on  the 
left  by  the  costal  edge  as  low  as  the  ninth.  The  free  border  or  greater 
curvature  can  be  determined  by  percussion.  Begin  above  at  the  edge 
of  the  liver  and  pei'cuss  gently  downwards  fi-om  this  line  of  dullness 
until  a  slight  alteration  in  the  pitch  of  the  tympanitic  percussion  note 
indicates  that  the  transverse  colon  has  been  reached.  Tliis  line,  which 
marks  the  greater  curvature  of  the  stomach,  bo\\s  downward  from  the 
free  end  of  the  tenth  rib  on  the  left,  crosses  the  middle  line  a  little 


Fig.  66 — Normal  position  of  the  stomach,  according  to  Rosenlieim   (solid  line). 
Dotted  line,  normal  position  according  to  Eichhorst. 

above  the  umbilicus  (1"  to  2"),  thence  curves  upward  to  the  edge  of 
the  thorax  where  it  meets  the  right  parasternal  line. 

The  cardiac  end  or  fundus  reaches  as  high  as  the  sixth  cartilage 
being  behind  the  heart  apex.  The  cardiac  orifice  is  opposite  the 
seventh  left  costal  cartilage  about  one  inch  from  the  sternum 
(Treves). 

The  pylorus  varies,  but  its  mo.st  frequent  position  is  to  the  right 
of  the  middle  line  two  to  three  inches  below  the  sterno-xj-phoid  articu- 
lation. This  point  corresponds  with  the  level  of  the  twelfth  thoracic 
spine. 


DISEASES  OP  THE  ABDOMEN  267 

For  diagnostic  purposes  the  stomach  may  be  distended  either  by 
inflating  it  with  air  or  by  means  of  an  effervescing  powder.  Air  may 
be  introduced  through  the  stomach  tube  by  means  of  a  hand  bulb. 
The  powder  consists  of  a  teaspoonful  of  tartaric  acid  dissolved  in  a 
half-tumberful  of  water  and  swallowed,  >  be  immediately  followed 
by  a  teaspoonful  of  sodium  bi-carbonate  also  dissolved  in  a  half- 
tumblerful  of  water  and  the  gas  retained.  The  resulting  distention  is 
usually  visible  and  the  outline  may  be  thus  determined. 

Knapp  describes  a  simple  method  for  locating  the  lower  border  of 
the  stomach,  which  J.  have  found  useful. 

The  patient,  .standing  erect  with  the  abdomen  covered,  drinks  a 
glass  of  cold  water.  After  the  lapse  of  half  a  minute  the  examiner 
places  his  hand,  which  must  not  be  cold,  against  the  bare  abdomen. 
The  lower  limit  of  the  cold  region  is  quite  definite,  and  denotes  the 
position  of  the  fundus  and  greater  curvature  of  the  organ. 

Lincoln,  by  a  method  of  transillumination  of  the  stomach  by  the 
use  of  fluorescin,  gives  results  bearing  upon  the  position  of  the  lower 
border  of  the  visciis  in  thirty  cases.  In  four  he  found  it  above  the 
umbilicus,  in  four  at  the  level  of  the  umbilicus,  in  twenty-two  below 
that  level.  He  leads  us  to  infer  that  only  eleven  of  those  examined 
had  gastroptosis ;  and  concludes  that  the  stomateh  lies  much  lower  in 
the  healthy  individual,  male  and  female,  than  generally  has  been 
described. 

Enlargements  of  the  stomach  may  be  recognized  by  palpation  and 
percussion ;  diminution  in  its  size  cannot  be  told  by  physical 
exploration. 

Increase  in  the  size  of  the  stomach  may  be  temporary  or  per- 
manent. Temporary  distentions  are  of  daily  occurrence  and  cannot 
be  regarded  as  pathologic.  They  are  caused  by  accumulations  of  gas 
or  the  ingestion  of  large  quantities  of  liquids  or  solids.  Treves  gives 
the  average  capacity  of  the  stomach  as  about  five  pints  (two  to  three 
litres).  This  is  certainly  too  great,  three  points  (1%  litres)  being 
more  nearly  correct.  The  elder  Leidy  used  to  say  that  stomachs 
which  have  never  been  over-distended  were  filled  by  a  pint  but  could 
be  stretched  to  two  quarts  (two  litres). 

Gaseous  distention  of  the  stomach  is  recognized  by  the  note  of 
large  tympany  heard  over  an  extended  area.  It  should  not  be  diffi- 
cult to  separate  this  sound  from  the  note  of  the  colon,  unless  the 
■latter  is  also  greatly  distended.     When  the  stomach  is  distended  by 


•26S 


DISEASES  OK  TIIK  ABDO.MKN 


liquid  or  solid  contents  tlif  nuriiial  tyiii|)aiiit  ic  note  is  wantiiif,',  and 
the  dnll  area  which  replaces  it  will  extend  from  the  liver  edge  down 
to  the  umbilicus,  and  outward  on  the  left  until  it  fuses  with  the 
splenic  dullness.  When  the  stomach  is  partly  filled,  as  some  time 
after  a  meal,  the  contents  gravitate  to  the  dependent  part  or  eul-de- 
sae  and  the  didlness  is  limited  to  that  portion  of  the  organ.  For  th.>- 
purpose  of  detecting  these  conditions  percussion  should  be  made  with 


Fig,  67 — Position  of  stomach  in  moderate  ga3tropto.sis  (  Rosenlicim's  description). 


the  patient  .standing.  In  case  the  viscus  is  empty  this  is  sufficient, 
but  if  partially  filled  the  percussion  should  first  be  made  with  the 
patient  erect,  noting  the  dull  area,  then  repeated  with  the  patient 
lying  upon  his  back,  when  the  dull  area  will  be  replaced  by  the  char- 
acteristic tympany. 

Almost  all  forms  of  dyspej^sia  and  conditions  in  which  .stasis  of 
the  gastric  contents  occurs  are  associated  with  gas  formation  and  tcm- 
porar\^  distention.  The  stomachs  of  beer-drinkers  are  apt  to  be  dis- 
tended. The  increase  in  size  may  be  permanent,  as  in  gastrcctasia, 
which  is  a  permanent  increase  in  the  volume  and  capacity  of  the 
stomach,  arising  from   iiiusenlar  atony,  or  in   pyloric  obstruction,  in 


DISEASES  OF  THE  .VBDOilEN  269 

which  the  condition  is  brought  about  by  the  gradual  stretching  of  the 
walls  by  the  retained  contents. 

Physical  signs  of  Gasfrectasia.  Inspection  may  reveal  the  out- 
lines of  the  organ,  espeeiallj'  the  greater  curvature,  which  extends  as 
low  as  the  navel  and  even  lower.  As  these  eases  are  very  generally 
accompanied  by  descent  of  the  organ,  the  upper  curvature  may  some- 
times show  itself  circling  beneath  the  ensiform  cartilage. 

Palliation.  The  air  ciishion  sensation  is  often  recognizable  by 
the  touch. 

Percussion  furnishes  trustworthy  evidences  of  dilatation.  We 
begin  above  and  percuss  downward  to  the  colon,  observing  the  pre- 
cautions mentioned  as  to  the  change  of  position  of  the  patient.  If 
the  viscus  is  empty  the  ingestion  of  a  large  glass  of  water  will  cause 
the  lower  tympanitic  border  to  be  replaced  by  dullness  when'  the 
patient  is  erect.  The  double  percussion  is  conclusive.  If  doubt  re- 
mains a  stiff  sound  may  be  passed  and  the  end  felt  through  the 
abdominal  wall,  or  the  sound  may  be  pushed  along  the  great  curvature 
until  it  encounters  the  resistance  of  the  pylorus  and  the  abnormal 
distance  noted.  If  the  lower  limit  of  the  stomach  reaches  below  the 
navel  the  conclusion  that  the  organ  is  dilated  is  justifiable.  The 
stomach  tube  may  be  used  for  filling  the  organ  with  water  in  order  to 
displace  the  tjTiipanitic  note,  but  is  seldom  necessary. 

CANCER  OF  THE  STOMACH. 

One  in  five  of  all  primary  cancers  attacks  the  stomach,  about 
two-thirds  of  the  cases  attack  the  pylorus. 

Inspection.  In  the  early  stages,  negative.  After  cachexia  and 
emaciation  set  in  the  tumor  may  be  visible. 

Palpation.  Tenderness  may  be  present  long  before  a  tumor  can 
be  felt.  When  palpable,  tumor  of  the  pylorus  is  generally  situated 
near  the  umbilicus,  owing  to  the  displacement  caused  by  dilatation, 
and  is  freely  movable,  changing  its  position  -with  varying  conditions 
of  the  organ  and  the  body. 

Percussion  gives  an  area  of  dullness — not  flatness — over  the  tumor 
wherever  it  may  be  situated.  The  percussion  should  be  performed 
when  the  stomach  is  empty  or  has  been  washed  out,  when  the  contrast 
of  tympany  and  muffled  dullness  is  more  manifest.  Pyloric  stenosis, 
which  results  in  most  cases,  causes  gastric  dilatation  with  the  physical 


270  DISEASES  UF  THE  AUUU.MEN 

signs  of  that  conditiou.     Sometimes  peristalsis.  stopi)iiiL;  sliori  at  tin- 
pj'lorus,  may"  be  seen. 

Other  sj-mptoms  are  those  of  dyspepsia  and  debilitx- :  vomit  which 
contains  blood  ("coffee  grounds");  diminished  or  absence  of  HCl 
and  the  presence  of  lactic  acid  in  the  stomach  contents. 

DISEASES  OP  THE  SMALL  INTESTINE. 

Aiialiiiiijj.  The  small  intestine  extends  from  the  pylorus  to  its 
junction  with  the  large  intestine  in  the  right  iliac  fossa  and  has  an 
average  length  of  seven  meters.  It  is  divided  into  the  duodenum, 
30  centimeters  long;  three-fifths  of  the  remainder  constitutes  the 
jejunum,  the  balance  foi-ming  the  ileum.  There  is  little  histologic 
distinction  between  the  two  structures.  Two  kinds  of  glands  ai'e 
found  in  the  walls,  secretory — the  glands  of  Brunner  and  Lieber- 
kiihn — and  the  agminated  glands  or  Peyer's  patches  and  the  solitary 
follicles. 

Peristalsis.  Dm'ing  digestion  the  gut  is  subject  to  certain  move- 
ments designed  to  propel  forward  its  contents,  called  peri.stalsis. 
These  movements  are  wave-like — peristalsis  proper — pendular  and 
rolling.    Violent  painful  peristalsis  is  called  tormina. 

The  functions  of  the  intestines  are  absorption  and  excretion.  A 
considerable  quantity  of  gas  is  always  found  within  the  lumen,  derived 
from  the  stomach,  the  blood  or  formed  within  the  canal  (see  Pa?ces). 

Pre^-ious  diseases,  habits,  occupation,  diet  and  the  use  of  special 
substances  as  alcohol,  tobacco  or  drugs  should  be  tlie  subject  of  careful 
inquiry  in  intestinal  affections. 

The  principal  facts  to  be  elicited  are  as  to  the  existence  of 

(a)  Pain;  its  seat,  character,  duration,  relation  to  digestion, 
evacuations,  eructations  and  food  inge-stiou :  how  influenced  by  rest, 
motion  or  pressure. 

(b)  Tympanites.  Sudden  tympanites  should  suggest  obstruc- 
tion, especially  if  inability  to  pass  gas  co-exists. 

(c)  Constipation,  its  duration  and  nature. 

(d)  Diarrhoea,  the  character  of  the  stools   (see  Section  XVI). 

(e)  Tenesnuis.  This  usually  indicates  an  affection  of  the  large 
intestine. 

The  maladies  of  the  small  intestine  individually  considered  do 
not  give  rise  to  definite  correlated  groups  of  distinctive  physical  signs, 
hence   these  manifestations   mav  be   considered   together,   afterwards 


DISEASES  OF  THE  .\BD03IES"  2(1 

pomting  out  the  differential  characters  along  with  the  special 
STmptoms. 

Inspection  is  not  limited  to  the  abdomen,  but  the  chest,  the  back 
and  the  anal  region  should  be  carefully  viewed.  The  examination  is 
best  made  upon  a  hard  bed  or  couch  with  as  perfect  relaxation  as 
possible.  The  import  of  various  superficial  vascular  conditions  is 
referred  to  elsewhere.  Irregrdarities  of  contour,  the  condition  of  the 
skin,  the  presence  of  ascites  or  oedema  are  especially  to  be  noted. 
Ewalt  says  small  new-growths  are  often  easier  to  recognize  by  in- 
spection than  by  palpation.  Wasting  diseases,  cancer,  the  cachexias,, 
lead-colic  and  meningitis  give  rise  to  depressed  or  scaphoid  abdomen. 
The  contour  and  outline  should  be  inspected  with  the  eyes  on  a  level 
with  the  surface,  viewed  during  full  inspiration  and  forced  expii-a- 
tion.  Irregularities  are  sometimes  revealed  by  voluntary  muscular 
contraction  of  the  walls. 

In  nervous  and  emaciated  persons,  particularly  the  convalescent, 
and  in  those  with  relaxed  abdominal  walls  peristalsis  is  visible.  If 
general  and  confined  to  the  small  intestine  it  is  not  especially  signifi- 
cant. Stopping  short  at  a  given  point  it  indicates  obstruction.  Vis- 
ible peristalsis  of  the  large  intestine  is  pathologic  and  not  infrequently 
points  to  stenosis.  It  is  also  found  in  neurotics.  Dnring  attacks  of 
colic  sudden  forceful  peristaltic  discharges — tormina — (accompanied 
by  shifting  gaseous  contents)  are  often  visible. 

Palpation.  The  desirability  of  a  warm  room  and  warm  hands 
has  been  mentioned.  Palpate  first  the  superficial  parts,  then  the 
deeper  regions,  examining  first  with  the  patient  on  the  back,  then 
on  either  side,  lastly  in  the  knee-elbow  position.  A  number  of  writers 
ad\"ise  palpation  in  a  warm  bath. 

After  a  careful  examination  of  the  parietes,  the  deep  palpation 
best  proceeds  from  above  downward,  not  omitting  the  inguinal  and 
femoral  canals.  The  coui-se  of  the  large  intestine  shoidd  be  separately 
followed.  The  sigmoid  fiexui-e  is  easily  palpated.  An  increasing 
niimber  of  observers,  since  Edebohls.  claim  ability  to  palpate  the 
appendix — certainly  a  difficult  task. 

We  note  by  palpation  irregularities  of  distention,  pain,  sensitive- 
ness, tenderness,  succussion,  adhesions,  new-growths,  fsecal  accumu- 
lations.   As  to  the  last.  difiEerentiation  has  been  sufficiently  dwelt  on. 

Xew-growths  are  much  oftener  malignant  than  benign.  The  size,, 
mobility,  consistency,  contour  and  location  are  noteworthy. 


272  DISEASES  (IF  THE  ABDOMEN 

Cancer,  sarcoma  and  tubercular  jirowths  are  the  most  frequent. 

The  first  are  irregular,  hard,  nodular  and  seldom  attain  laru'e  size. 

The  second  smooth,  hard  and  may  be  large. 

The  third  vary  in  consistency,  are  diffused,  occur  in  young  sub- 
jects and  are  often  associated  with  tuberculosis  elsewhere.  Diarrhcea 
accompanies  these  while  the  former  are  associated  with  constipation. 

Percussion.  General  directions  upon  abdominal  percussion  and 
the  results  obtained  by  percussing  different  areas  have  been  given. 
We  search  for  departures  from  the  normal  note.  Successive  examina- 
tions, especially  after  freely  evacuating  the  bowels,  are  recommended. 
The  character  and  differences  in  the  sounds  elicited  have  been 
described. 

AvscultaUon  reveals  intestinal  sounds  such  as  sueeussion.  bor- 
borygmi  and  gurglings.  Little  of  practical  value  is  educed  from 
their  presence.  Their  absence  is  significant  of  paralysis  of  the  bowel, 
as  in  appendicitis,  or  of  perforation,  in  which  case  there  is  total 
absence  of  all  bowel  sounds.  In  stenosis  the  sounds  are  increased. 
Gurgling  in  the  right  iliac  fossa,  formerly  considered  a  diagnostic 
feature  of  typhoid  fever,  has  no  clinical  value. 

ULCER  OF  THE  DUODENUM. 

These  occiu-  at  any  age,  even  in  the  new-born,  hut  are  most  fre- 
quent between  the  ages  of  thirty  and  fifty,  ^len  are  more  frequently 
affected  than  women.  The  symptoms  are  similar  to  those  of  gastric 
ulcer,  for  which  the  disease  is  apt  to  be  mistaken.  The  special  symp- 
tom is  pain  which  appears  several  hours  after  eating.  The  situation 
of  this  pain  is  on  the  right  parasternal  line  .just  below  the  gall  bladder. 
It  has  been  found  that  diminishing  the  acidity  of  the  gastric  juice  or 
temporarily  suppressing  its  flow  through  the  pylorus  relieves  this 
pain,  a  feature  which  distinguishes  the  disease  from  gastric  ulcer. 
Administering  acid  wines  or  food  accomplishes  the  purpose.  Tender- 
ness, reflex  vomiting,  hajmatemesis  and  blood  in  the  stools  summarize 
the  symptoms.  The  gastric  contents  give  no  definite  indications.  Per- 
foration or  fatal  hemorrhage  may  occur. 

ACUTE  AND  CHRONIC  INTESTINAL  CATARRH. 

These  may  be  classed  as  infectious,  alimentary,  climatic,  medicinal 
and  toxic  catarrhs.  The  first  is  primary  or  a  complication  of  existing 
■disease ;  the  second  includes  the  larger  majority  of  all  cases. 


DISEASES  OF  THE  jVBDOMEN  273 

The  general  sjouptoms  are  pain,  nausea,  diarrhoea  with  much  or 
little  mucus.  The  presence  of  green  bile  in  the  dejecta  indicates  that 
the  disease  is  in  the  upper  intestine.  General  lassitude  and  weakness 
supervene.  The  stomach  is  often  involved.  Fever  is  slight  or  absent. 
The  iirine  is  scanty  and  not  seldom  albuminous. 

The  diagnosis  is  easy.  Large  masses  of  mucus  and  an  admixture 
of  blood  with  the  faeces  point  to  the  large  intestine  as  the  seat  of  the 
disease.  Local  tenderness  aids  in  locating  it.  The  main  symptom  is 
the  altered  condition  of  the  faces. 

The  symptoms  of  the  chronic  form  are  similar  but  less  acute. 
Constipation  is  not  incompaiihle  with  this  form,  a  fact  to  be  remem- 
bered.    Constipation  and  diarrhcea  may  alternate  in  chronic  catarrh. 

Membranous  colitis  is  a  form  of  catarrh  accompanied  by  painful 
spasm  of  the  intestine,  alteration  of  function  and  the  occurrence  in 
the  stools  of  mucus  which  assumes  the  form  of  membrane  or  casts. 
Females  are  usually  the  subjects  of  the  disease  and  constipation  marks 
the  preponderance  of  the  eases. 

Intestinal  obstruction  or  stenosis  may  affect  the  small  or  the  large 
bowel.  The  causes  are  formation  of  ligamentous  bands,  the  occur- 
rence of  hernia,  impaction  by  gall  stones,  foreign  bodies  (food,  faecal 
impactions),  intestinal  concretions,  compression  from  organs  or 
growths  and  intussusception.  Band  or  slit  strangulation  and  intus- 
susception account  for  ninety  per  cent,  of  the  cases.  Dilatation 
develops  above  the  obstruction  and  is  greater  the  nearer  the  difficulty 
is  to  the  rectum.  For  this  reason  when  the  jejunum  is  the  seat, 
involvement  and  over-distention  of  the  stomach  quickly  intervene. 
Constipation  comes  on  as  soon  as  obstruction  is  complete  but  may  have 
been  preceded  bj^  diarrhcea.  The  peristalsis  is  augmented  and  is  visible, 
occurring  in  intermittent  painful  spasms.  The  character  of  the  stool 
is  not  significant.  In  certain  cases  bile  is  constantly  found  in  the 
stomach.  The  subjective  symptoms  are  loss  of  appetite  and  strength, 
nausea,  fullness  and  a  peculiar  distress.  Eructations  and  vomiting 
mark  most  cases.  Visible  peristalsis  and  intestinal  rigidity  are  the 
most  important  physical  signs.  Suddenly  developed  constipation, 
resistant  to  cathartics,  occurring  in  one  of  regular  habits  should  excite 
grave  suspicion,  particularly  if  the  patient  is  of  advanced  age. 

Complete,  rapidly-developed  obstruction  involving  one  or  more 
intestinal  coils,  is  called  ileus.  The  symptoms  are  great  pain,  nausea, 
vomiting  and  suppression  of  faces  and  gas.     The  vomiting  if  con- 


•_'(4  [>ISEASKS  OK  THE  ABDllMli.N 

tinned  lu'comi's  stt'rc't)ra(.'eoiis.  Iiicareerated  heruia  is  the  most  fre- 
(|nent  and  potent  cause.  Tympanites  develops,  but  spasmodic  peris- 
talsis is  generally  absent.  The  distended  and  resistant  portion  of  the 
intestine  before  the  obstruction  can  generally  be  recognized  by  pal- 
liation and  inspection.  In  hernia,  palpation  recognizes  the  incar- 
cerated bowel  by  the  impulse  communicated  on  coughing. 

Obstruction  may  be  mistaken  for  biliary  or  renal  colic,  but  the 
history,  the  presence  of  .iaundice,  enlarged,  tender  liver  or  kidney, 
bile,  blood  or  other  foreign  substance  in  the  urine  aid  in  recognizing 
these  while  marked  indicanuria  points  to  obstruction.  The  symptoms 
tending  to  exclude  peritonitis  are  given  thereunder. 

Volvulus  is  a  twist  of  the  intestine  upon  its  mesentery,  or  a 
knotting  of  two  or  more  intestinal  coils.  The  sigmoid  fiexure  is 
oftenest  involved,  next  the  ascending  colon. 

As  a  rule  it  is  an  accident  of  late  or  middle  life. 

Pain,  absence  of  faeces  and  Hatus,  local  tympanites  and  vomiting 
are  present.  Tenesmus  is  inconstant.  The  fteees  below  the  twist, 
when  evacuated,  may  contain  blood.  Constipation  resistant  to  cathar- 
tics follows. 

Palpation.  Sometimes  the  fle.xion  can  be  paljialed.  or  \vt'  may 
discover  in  the  lower  abdomen  near  the  median  line  a  resistant,  air- 
cushion  tumor  of  varying  size. 

Poxussion  evolves  dullness  or  tympany  according  as  the  sigmoid 
is  full  or  empty.  ^Metallic  tinkling  is  occasionally  heard.  The  inune- 
diate  return  of  water  injected  into  the  rectum  and  the  ability  to  in.iect 
only  small  quantities  aid  in  the  diagnosis. 

Infussuscci}iion  is  the  invagination  of  one  portion  of  the  intestine 
within  the  lumen  of  another  portion.  It  may  occur  at  any  age,  but  is 
especially  prone  to  att'ect  infants  and  young  children,  and  appears 
suddenly. 

Symptotm.  Spasmodic  pain,  tenesmus,  blood  in  the  stools,  which 
continue  until  the  distal  portion  of  the  bowel  is  evacuated,  and  the 
presence  of  a  palpable  tumoi-.  hard  and  sausage-like,  over  the  ascend- 
ing or  transverse  colon  make  certain  the  diagnosis.  Blood  in  the  stool 
is  found  in  over  eighty  per  cent,  of  the  cases.  Intussusception  oc- 
eurrinff  during  the  death  agony  is  not  to  be  mistaken,  when  found 
post-mortem,  for  the  above. 


DISEASES  OF  THE  _VBDOiIEN  275 

GALL  STONE  DISEASE. 

Sjiionynis:  Cholelithiasis.  Hepatic  Colic.  Lithogenons  Biliary 
Catarrh. 

Definition.  An  acute  or  chronic  affection  of  the  gall  bladder 
and  ducts,  generally  inflammatory,  resulting  in  the  formation  of 
calculi. 

Bacterial  invasion  is  a  potent,  if  not  the  sole,  cause. 

The  sufferers  are  generally  women  who  have  borne  children  ;■ 
persons  between  the  ages  of  thirty-five  and  fifty.  In  many  cases 
stones  exist  without  causing  inconvenience.  Stones  are  single  and 
large,  or  multiple  and  small.  Permanent  obstruction  of  the  cystic 
duct  results  in  dropsical  enlargement  of  the  bladder — hydrops  vesica 
fellece — which  results  in  a  cystic  tumor  discernible  in  the  upper 
abdomen,  and  easily  recognized. 

The  general  symptoms  of  the  colic  are  produced  by  the  passage 
of  the  stone  through  the  duct  or  by  its  lodgment  therein.  The  former 
is  the  cause  of  ordinary  biliary  colic. 

Symptoms.  Pain,  severe,  even  agonizing,  which  comes  on  sud- 
denly. Generally  centering  in  the  right  hj'poehondriac  region  it 
radiates  over  the  epigastrium,  lower  thoracic  region  and  into  the  right 
shoulder  and  arm. 

Palpation.  Tendei'ness  which  centers  over  the  gall  bladder  is: 
manifest  and  the  bladder  may  be  palpable.  With  relaxed  abdominal 
walls  gall  stone  crepitus  is  occasionally  felt  when  the  bladder  is  not 
over-filled  with  stones  and  its  walls  are  not  too  tense.  Occasionally 
the  muscles  of  the  right  side  are  rigid.  Enlargement  and  tenderness 
of  the  liver,  and  enlargement  of  the  spleen,  are  discoverable  by  palpa- 
tion and  percussion.  When  the  stone  reaches  and  blockades  the  com- 
mon duct  it  produces  .jaundice,  which  may  be  slight  and  transient,  or 
intense  and  protracted.  The  colic  lasts  hours  or  days,  ending  sud- 
denly with  the  discharge  of  the  calculus  into  the  bowel.  (For  recov- 
ery and  recognition  of  gall  stones,  see  Section  XVI.)  Rigor  and 
chill  are  occasional.  Fever  is  generally  present;  temperatures  of 
102° — 103°  are  common,  105°  is  exceptional.  Vomiting  and  pro- 
tracted nausea  are  usual.  The  urine  contains  bile  when  .jaundice 
occurs,  and  bile  in  the  urine  frequently  precedes  its  manifestation  in 
other  localities.  Albumin  and  red  blood  corpuscles  are  found  in 
most  cases. 


276  DISEASES  OF  THE  ABDtMEN" 

Di/)\n  iitiiil  Dicujiiiiais.  The  location  of  the  exfriiuiating  pain 
and  tenderness  are  almost  sufficient.  If  jauudice  occurs  the  diajriiosis 
is  sure.  Stone  should  always  be  sought  for  in  the  stools.  History 
of  previous  attacks  greatly  aids. 

From  renal  colic  it  differs  in  the  location  and  character  of  the 
pain.  There  the  paiu  is  in  the  lower  abdomen,  radiates  to  irroin  and 
testicle:  icterus  is  not  present,  nor  is  bile  found  in  tlie  urine.  Gas- 
tralgia  is  withoiU  chill,  fever  or  jaundice:  vomiting  is  rare.  Pressure 
and  food  ingestion  afford  relief.  The  attacks  are  periodical  and  a.sso- 
ciated  with  general  nervous  manifestations. 

APPEXDICITIS. 

D(  filiitioii.  Ah  inrtammation  of  the  vermiform  appendix  caused 
by  the  invasioTi  of  micro-organisms.  The  diseas<>  may  be  aent:"  or 
chronic. 

The -recognized  varieties  are:  Catari-hal.  Iiiteistilial.  rieerative. 
Gangrenous. 

The  effects  of  extension  of  the  inflamniation  beyond  its  original 
bounds  are  circumscribed  or  diffuse  abscess,  and  peritonitis  which 
may  be  limited  or  general.  These  results  are  brought  about  by  exten- 
sion of  inflannnation,  by  perforation  or  by  gangrene. 

Catarrhal  appoidicitis  may  result  in  immunity  from  further 
attacks  by  adhesion  of  the  contiguous  surfaces  producing  obliteration 
of  the  lumen — a  fortunate  but  rare  result.  Obliteration  of  the  prox- 
imal portion  may  result  in  abscess  or  cyst  of  the  distal  part.  Foreign 
Ijodies  are  occasionally  found  in  the  appendix,  fipcal  concretions  fre- 
quently, but  their  influence  in  producing  disea.se  has  been  over-esti- 
mated. The  possibility  of  tubercular  and  typhoid  ulceration  of  the 
appendix  mu.st  be  kept  in  mind. 

Children  and  young  adult  males  are  the  most  frequent  subjects 
of  attack. 

Sympto))is  and  physical  signs.  The  lighter  grades  of  the  disease, 
especially  the  catarrhal  variety,  undoubtedly  often  pass  luinoticed  or 
occasion  only  slight  pain,  passing  fever  and  some  disorder  of  the 
bowels.  The  interstitial  form  gives  rise  to  more  definite  s.\Tnptoms, 
occasioned  by  involvement  of  the  peritoneal  coat.  The  gangrenous  and 
ulcerative  forms  may  be  insidious  but  usually  give  rise  to  definite 
sjnnptoms.  The  oncome  of  gangrene  sometimes  lulls  the  pain  and 
masks  the  pre-existing  signs. 


DISEASES  OF  THE  ABDOMEX  2l  I 

The  first,  most  constant  and  invariable  sign  of  appendicitis  is 
pain,  paroxysmal  or  colicky.  In  the  beginning  this  initial  pain  is 
intermittent  or  remittent,  variable  as  to  seat  and  severity.  Oftenest 
centering  around  the  iimbiUcns  or  over  the  epigastrium,  less  often  in 
the  right  iliac  fossa,  it  finally  settles  over  the  seat  of  the  appendix  after 
a  time  varying  between  twelve  and  thirty-six  hours.  If  the  organ  is  in 
an  anomalous  position  the  seat  of  pain  will  be  likewise.  The  general 
location  is  now  in  the  fossa  at  a  point  on  a  line  drawn  from  the 
umbilicus  to  the  right  anterior  superior  iliac  spine,  distant  one  and 
one-half  to  two  inches  therefrom.  This  point  is  external  to  the  rectus 
muscle  and  is  known  as  ilcBurney's  point.  The  pain  is  called  the 
secondary  pain. 

Allied  to  pain  is  tenderness,  the  second  cardinal  symptom.  This 
may  be  limited  to  a  rather  small  area  siirrounding  the  underlying 
inflammatory  focus  or  may  extend  over  the  entire  right  half  of  the 
abdomen.  Not  infrequently  the  lower  right  quadrant  limits  the  ten- 
derness. When  the  entire  belly  is  affected  it  points  to  an  extension 
of  inflammation  beyond  the  original  focus.  The  seat  of  maximum 
tenderness  and  maximum  pain  usually  coincide  and  correspond  to 
the  point  named  above,  but  the  pain  may  subside  and  the  tenderness 
remain.    In  case  of  suppiiration  the  tenderness  becomes  exquisite. 

As  first  pointed  out  by  Deaver.  the  third  most  significant  symp- 
tom of  appendicitis  is  rigidity  of  the  muscles  of  the  right  side  of  the 
abdomen,  particularly  the  right  rectus.  This  rigidity  comes  on  eai-ly 
and  lasts  throughout  the  primary  stage  of  the  disease,  or  iintil  sup- 
piiration,  abscess,  peritonitis  or  declination  of  the  inflammation 
succeeds. 

In  case  the  disease  progresses  unfavorably  the  pain,  tenderness 
and  muscular  rigidity  may  subside,  or  are  wholly  or  partly  replaced 
after  a  varying  time,  generally  two  or  three  days,  by  a  localized  swell- 
ing, or  by  a  general  distention  of  the  abdomen.  The  local  swelling 
varies  in  size  and  consistency  but  is  usually  above  the  size  of  a  small 
lemon,  lying  weU  within  the  iliac  fossa  above  Poupart's  ligament. 

Peritonitis  resulting  from  suppuration  does  not  differ  in  its 
manifestations  from  peritonitis  herein  described  due  to  other  causes. 

Vomiting  is  a  general  and  early  symptom.  While  usually  ceasing 
with  the  evacuation  of  the  stomach,  occasionally  bile  and  even  ffecal 
matter  are  vomited.  Continued  vomiting  is  an  imfavorable  omen,  as 
is  likewise  hiccough. 


278  DISEASES  OP  THE  jUJDOMEN 

Fi  rtr  is  always  pie.sciit.  Alllidiijili  in  tlic  early  stau'es  its  severity 
can  not  be  accepted  as  an  index  of  the  gravity  of  the  attaciv,  yet  in 
general  its  decline  is  a  favorable  symptom.  Snppuration  is  accom- 
panied by  a  maintained  or  rising  temperature.  The  characteristic  pus 
curve  rarely  is  present.  Suppuration  may  occur  after  the  decline  of 
the  fever,  as  may  also  gangrene.  Continued  or  increased  tenderness 
is  a  valuable  sign  of  these  conditions. 

A  sudden  fall  of  temperature,  cold  bedewed  skin,  small  pulse,  in 
short  the  signs  of  collapse,  indicate  perforation.  It  is  to  be  remem- 
bered that  the  severity  of  the  disease  may  increase  without  any  ther- 
monieti'ic  warnings.    Even  afebrile  cases  are  said  to  occur. 

The  piilsr  varies  with  the  fever;  at  first  rapid  and  full,  with  un- 
favorable progress  of  the  disease  it  becomes  rapid,  small,  thready  and 
compressible.  Deaver  considers  the  pulse  changes  a  more  relialile 
index  to  the  disease  than  the  temperature  chart. 

The  bowels  are  usually  constipated  at  the  outset  aiul  the  niahuly 
very  rarely  succeeds  upon  an  attack  of  diarrhoea,  but  diiu ilnea  may 
intervene  after  the  beginning  of  the  attack,  and,  on  the  whole,  in  my 
own  experience  is  to  be  considered  a  favorable  symptom.  Alternate 
diarrhrea  and  constipation  may  occur  during  the  disease. 

The  urine  is  febrile,  may  contain  albumin  and  ea.sts.     As  men- 
tioned hereafter  the  presence  of  indican  is  indicative  of  supi)uration. 
Urobilin  is  often  present. 
The  blood  changes  are  given  in  Section  XII. 
Physical    Signs.    Inspection    in    most    ca.ses    is    negative.     The 
patient  usually  lies  upon  the  back  witli  the  right  leg  Hexed.     The 
expression  indicates  pain.    In  advanced  eases  the  look  is  anxious.    At 
first  thei'e  is  slight  retraction  and  fixedness  of  the  right  side.    If  tumor 
forms  swelling  is  observable  but  seldom   reaches  large   proportions. 
It  may  extend  backward  to  the  flank.    The  resultant  paralysis  of  the 
bowel  may  cauf;e  local  or  general  distention  of  the  abdomen.     Peri- 
tonitis is  accompanied  by  rapid  distention  of  the  abdomen  and  exten- 
sion of  the  swelling.    With  the  peritoneal  involvement  the  respiratory 
rh>-thm   is   interrupted,   the   abdomen    restrained   and   the   breathing 
becomes  costal. 

I'alpafion.  The  dil'ferenee  in  the  degree  of  resistance  offered  by 
the  two  recti  muscles  is  marked  and  continues  throughout  the  first 
stage  of  the  malady.  On  deep  palpation  an  area  of  resistance  corre- 
sponding to  the  extent  of  the  disease  is  often  encountered  in  the  right 


DISEASES  OF  THE  ABDOilEX  279 

iliac  fossa.  This  area  is  generally  oblong  with  the  axis  parallel  to 
Poupart's  ligament.  The  tenseness  of  the  abdominal  walls  may  inter- 
fere with  the  manifestation.  If  actual  tumor  is  present  it  is  generally 
palpable  and  is  signitieant.  Fluctuation  is  detected  only  in  rare  eases. 
Pain  and  tenderness  are  manifest  on  palpation.  A  difference  in  the 
temperature  of  the  two  sides  is  sometimes  observable. 

Peirussion  shows  a  localized  area  of  impaired  resonance  sur- 
rounded by  tjinpany.  ^Marked  flatness  seldom  obtains.  Paralysis  of 
the  bowel  with  resultant  distention  increases  markedly  the  tympany. 
Overlying  intestine  may  mask  the  dullness. 

Auscultatian  may  aid  percussion  in  delimiting  the  tumor.  Dis- 
tention due  to  accumulation  of  gas,  and  distention  caused  by  intes- 
tinal paralysis  may  be  differentiated  by  auscultation.  In  the  first  the 
peristaltic  sounds  are  present ;  in  the  second,  absent. 

Differential  Diag)iosis.  When  the  sjTnptoms  described  are  pres- 
ent the  diagnosis  is  comparatively  easy.  When  most  of  them  are 
absent  the  cases  require  careful  consideration.  Sudden  attacks  of 
intestinal'  colic  due  to  food  irritation  are  most  confusing.  But  the 
history  of  the  ease,  the  rapidly  succeeding  diarrhoea,  the  absence  of 
tenderness  in  the  right  fossa  and  the  relief  which  succeeds  upon  free 
purgation  decide  the  matter. 

Obstruction  of  the  bowel  may  be  mistaken  for  appendicitis, 
or  vice  versa.  Obstruction  is  primarily  afebrile,  the  pain  may  be 
located  at  any  point,  peristalsis  is  absent.  Other  features  of  that  con- 
dition are  detailed  elsewhere.  Fa?cal  accumulation  should  not  be 
mistaken  for  tumor.  Ovarian  inflammation  can  be  excluded  by  bi- 
manual examination.  Floating  kidney  is  movable.  In  nephritic  colic 
the  pain  is  deeper-seated  and  radiates  into  the  testicle  and  groin.  The 
urine  gives  evidence  of  the  kidney  affection. 

THE  LARGE  INTESTINE. 

The  colon  begins  with  the  ctecum  in  the  right  iliac  fossa,  passes 
vertically  upwards  on  the  right  side  to  reach  the  under  surface  of  the 
liver,  traverses  the  cavity  below  the  stomach  to  the  spleen,  makes  a 
second  rectangular  bend  and  descends  into  the  left  iUac  fossa  as  the 
sigmoid  flexure  and  rectum.  Its  length  varies  extremely,  being  some- 
times a  trifle  over  a  yard  and  at  others  being  over  two  yards  long. 
(1  to  2  m.) 

The  larse  intestine  encircles  the  small  intestine  horseshoe-like. 


280  DISEASES  OP  THE  AUnojIEN 

Inspection.  Oeca.si()ii;ill\'  in  liailly-iHiurislu'il.  iii;ii  asiuatic  and 
i-icketj'  childriMi  the  outline  of  the  distended  transverse  colou  may  be 
distinctly  seen.  The  peristaltic  movements  of  the  bowels  may  be  seen 
occasionally  in  health  and  when  increased  are  more  visible. 

Palpation.  When  the  colon  is  distended  with  solid  or  semi-solid 
contents  the  enlargement  may  be  felt.  The  ftrcal  contents  are  most 
ai)t  to  accumulate  in  the  left  iliac  fossa,  then  in  the  right,  but  even 
the  transverse  colon  may  be  filled.  These  accunudations  are  recog- 
nizable on  palpation  by  their  peculiar  lack  of  ela.st.icity,  and  although 
hard  and  resistent.  when  pressed  upon  by  the  ends  of  the  fingers  they 
indent  like  a  hard  snow-ball  and  the  indentation  remains  after  the 
removal  of  pressure  (Simpson). 

Pcrcuxmon.  The  note  of  the  enii)ty  colon  is  more  truly  tympan- 
itic than  that  of  the  stomach;  its  quality  is  somewhat  amphoric.  By 
percussion  the  situation  of  the  solid  aggregations  of  the  bowels  may 
be  marked  out  on  the  surface.  Dullness  is  more  apt  to  olitain  over 
the  descending  colon  than  over  the  ascending,  and  Bennett  points 
out  the  practical  value  of  this  fact  in  determining  whether  the  patient 
should  be  given  a  purgative  or  an  (jnema.  If  dullness  is  found  in  the 
right  fossa  an  enema  will  fail  to  relieve  the  bowel  and  a  purgative 
is  indicated. 

These  accumulations  might  be  mistaken  for  enlargements  of  the 
spleen  and  liver  but  their  peculiar  feel  and  their  transitory  nature 
shoTild  distinguish  them. 

Enteroptosis,  or  falling  of  the  intestines,  gives  rise  to  no  recog- 
nizable physical  signs.  Coloptosis,  or  descent  of  the  large  intestine,  in 
wliich  the  transvei'se  colon  may  lie  upon  the  symphysis,  may  be  i-ecog- 
nized  by  percussion. 

DYSENTERY. 

Definition.  An  acute  or  chronic  infectious  inlhumiiation  of  the 
large  bowel  characterized  by  frequent  bloody,  mucous  or  serous  evacu- 
ations, associated  with  tormina  and  tenesmus. 

Two  forms  are  recognized,  bacillary  and  amcebie.  The  disease  is 
ejiidemie  and  universal.  Shiga  and  Plexner  have  each  isolated  a 
bacillus. 

Of  the  tirst  form  acute,  catai-rhal.  croupous  and  h-emorrhagie 
varieties  are  recognized.     Either  form  may  lie  ehronic.     The  liver  is 


DISEASES  OP  THE  ABDOMEN  281 

often  involved  and  abscesses,  minute,  multiple  or  large,  of  this  organ 
are  not  infrequent. 

Symptoms.  Frequent  stools,  abdominal,  colicky  pains  and  fever 
mark  the  simple  acute  form.  In  the  catarrhal  variety  the  stools  are 
more  frequent,  twentj^  to  fifty  daily,  diarrhoeal,  consisting  principally 
of  mucus  admixed  with  blood,  and  voided  with  much  pain  and 
tenesmus. 

In  the  croupous  form  the  stools  are  mucoid  and  bloody  from  the 
beginning  and  may  soon  consist  almost  entirely  of  blood.  The  evacu- 
ations are  very  frequent  and  accompanied  by  severe  tormina  and' 
tenesmus.  Recovery  is  slow.  Death  may  occur  from  exhaustion ;  per- 
foration, peritonitis  or  gangrene  of  the  bowel  may  supervene. 

Special  Symptoms.  Fever  is  slight  in  mild  cases,  moderate  in 
severe  cases,  seldom  exceeding  102°.  Amoebic  dysentery  may  be 
afebrile  or  the  temperature  may  be  comparatively  high,  reaching  104°. 

In  the  simple  catarrhal  form  pain  is  not  severe;  in  the  graver 
forms  pain  is  excruciating,  especially  if  due  to  ulceration,  but  is 
temporarily  relieved  by  the  passage  of  flatus  or  fseces.  The  passages 
are  difficult  and  require  much  painful  straining  effort. 

Tenderness  is  marked  over  the  entire  abdomen  and  with  ulcera- 
tion becomes  exquisite.  The  patient  lies  on  the  back  with  the  thighs- 
flexed.  Peristalsis  is  visible.  Tenemus  is  almost  continuous;  paraly- 
sis of  the  bowel  and  prolapse  of  the  rectum  often  occur.  Nausea 
and  vomiting  complicate  some  acute  cases,  as  do  also  strangury  and 
vesical  tenesmus.  Necrosis,  perforation  and  peritonitis  are  accidental 
complications  not  infrequent. 

The  stools  at  first  are  diarrhoeal  but  foacal  matter  may  entirely 
disappear  or  be  present  only  in  minute  quantities.  They  then  consist 
of  blood-stained  miicus  with  perhaps  small  fiecal  masses  intermingled. 
Blood,  either  red  or  chocolate  color,  may  be  passed;  tarry  stools  are- 
not  usual.  In  eases  of  gangrene  necrotic  masses  with  offensive  odor, 
dark-brown  or  black  in  color,  are  voided.  In  the  diphtheritic  variety 
pseudomembrane  and  dead  mucous  membrane  occur  in  the  stools. 
Bacteria,  amceba  and  other  organisms  abcflmd. 

Agglutination  test.  A  specific  serum  reaction  of  the  blood  simi- 
lar to  the  Widal  reaction  of  typhoid  fever  is  observed  in  most  cases, 
of  dysentery,  but  in  mild  cases  is  slight  or  doubtful.  It  is  limited  to 
the  bacillary  disease  and  does  not  take  place  prior  to  the  tenth  day. 

Differential  Diagnosis.     Cancer  of  the  rectum  is  slower  of  devel- 


282  nisKASEs  of  tiik  AnooxiKN 

opmeiil.  is  acconipaiiied  by  ('(iiistipation.  and  disiital  cxaiiiiiiatioii  or 
the  proctoseope  jreuerally  reveal  the  growth.  Particles  of  the  new- 
growth  are  found  in  the  stools  and  microscopic  examination  reveals 
thi'ir  nature. 

('(iiicir  of  the  bowrl  gives  no  physical  signs  other  than  those  of 
obstruction  unles.s  tumor  develops.  The  discharges  may  contain 
fi-a<>nients  of  tlie  growth,  mixed  with  pus  and  blood. 

TIIP]  LIVER. 

Perfect  familiarity  with  the  normal  boundaries  of  this  organ  is 
essential  to  the  study  of  the  physical  signs  indicative  of  its  maladies, 
since  the  diagnosis  in  cases  of  hepatic  disease  is  chiefly  determined 
by  the  recognition  of  alterations  in  its  size,  shape,  consistency,  position 
and  the  state  of  its  surface,  obtained  by  palpation  and  percussion.  The 
percussion  boundaries  of  the  organ  have  been  given  in  the  seetioi- 
on  medical;  anatomy.  It  is  necessary  to  remember  that  the  liver  is 
suspended  and  very  movable,  altering  its  position  under  various 
circum,stan6es.  It  is  depressed  with  each  inspiration,  its  lower  border 
pro.jectiug  below  the  ribs  with  a  full  breath.  It  recedes  under  the 
edge  of  the.  ribs  on  lying  down,  and  when  lying  ou  the  left  side  is  not 
in  close  contact  with  the  chest  wall.  In  children  the  gland  is  pi-opor- 
tioually  larger  than  in  adults  and  the  edge  is  always  palpable  below 
the  border  of  the  ribs  on  the  right,  and  the  left  lobe  extends  into  the 
left  hypochondrium. 

While  the  upper  boundary  of  the  liver  changes  but  little,  except 
in  conditions  which  cause  depression  of  the  diaphragm,  as  pleural 
effusion  and  emphysema,  which  have  been  discussed  in  the  .section 
upon  lung  and  pleura,  yet  it  is  necessary  to  determine  this  outline.  It 
is  done  by  light  percussion  from  above  downward  until  the  change  of 
note  in  the  overlying  lung  tells  us  that  a  solid  organ  has  been  reached. 
We  percuss  along  the  anterior  median  line,  the  right  nipple-line,  the 
mid-axillary  linp  and  the  right  mid-scapular  line  respectively,  and 
draw  a  pencil  through  the  points  so  determined.  The  boundary  will 
be  found  generally  to  eorres^^ond  to  the  base  of  the  ensiform  cartilage 
for  the  first  point,  the  fifth  right  interspace  for  the  second,  the  sev- 
enth rib  for  the  third,  and  the  ninth  rib  posteriorly  for  the  last.  The 
lower  border  is  easily  fixed  by  percussion,  as  the  change  from  flat- 
ness to  the  tympany  which  marks  the  contact  of  the  intestines  with 
its  free  border  is   unmistakable.     The   normal    widtli    is   about    four 


DISEASES  OF  THE  .iBDOilEN  283 

melies  measured  along  both  the  nipple  and  the  mid-seapular  lines, 
and  a  trifle  more  in  the  axillary.  In  women  who  have  been  the  vic- 
tims of  tight-lacing  these  widths  are  increased,  but  the  constriction  of 
the  waist  line  will  plainly  indicate  the  reason.  In  extreme  cases  the 
right  lobe  is  separated  by  a  transverse  fiu-row  or  band  and  the  lower 
portion,  which  is  abnormally  movable  may  extend  to  the  iliac  border. 
The  possibility  of  mistaking  this  artificial  lobe  for  an  abdominal  tumor 
or  movable  kidney  is  corrected  by  following  the  free  liver  edge  from 
the  epigastrium  dowTiward  and  from  the  lumbar  region  forward  until 
they  unite  at  the  doubtful  point.  In  other  cases  a  continuation  of 
dxdlness  on  percussion  without  interruption  to  any  considerable  extent 
below  the  right  border  of  the  ribs  points  to  the  liver  as  the  organ  dis- 
eased. 

Changes  in  the  Position  of  the  Liver.  Elongation  of  the  sus- 
pensory ligament  causing  floating  liver  is  very  rare.  Displacement 
to  the  right  or  left  or  tilting  of  its  lower  edge  is  associated  with  vari- 
ous abdominal  and  thoracic  affections. 

Changes  in  the  Size  of  the  Liver.  The  liver  is  increased  or 
diminished  in  size  in  almost  everj-  disease  to  which  it  is  subject. 

Its  size  is  increased  in  the  active  congestion  which  accompanies" 
many  diseases,  in  passive  hypersemia,  in  all  inflammations  causing 
obstruction  of  the  bile  ducts,  in  abscess,  in  fatty  and  dropsical  infil- 
tration, in  hj-pertrophy,  in  parenchymatous  and  amyloid  degenera- 
tions, in  hypertrophic  and  biliary  cirrhosis,  in  cancer,  cysts,  and 
echinoeoeeus  cyst  of  the  organ. 

The  volume  of  the  liver  is  dimiui-shed  in  atrophy,  in  acute  yellow 
atrophy  and  atrophic  cirrhosis,  in  fatty  degeneration  and  syphilis 
of  the  liver.  Perihepatitis  results  in  contraction  of  the  organ  by  pres- 
sure, and  tuberculosis  of  the  liver  is  usually  associated  with  cirrhotic 
contraction. 

Passive  hyperamia.  The  liver  is  enlarged,  tender  and  may  be 
the  seat  of  pulsations.  The  enlargement  is  sub.ject  to  variations, 
ascites  occurs  late :  .jaitndice  is  rare. 

Obstruction  of  the  bile  duets  is  associated  with  pain,  fever  and 
jaundice. 

Abscess  gives  rise  to  pain  or  tenderness,  fever,  chill,  sweats  and 
jaundice.  The  enlargement  may  be  iipward  into  the  axilla  especially 
if  the  lateral  or  the  posterior  part  of  the  right  lobe  is  the  seat  of 
abscess;   and  the  edge  is  pushed  downward  and  appears  below  the 


284 


PISKASES  OF  Till':  AHDDMICN 


edge  of  till'  rilis.  H'  Ihc  alisi/rss  is  sii|)crtici;il  :ind  Imi-lic.  soft  tliictiiM- 
tion  is  detected;  in  other  cases  tenderness  and  claslicity.  The  or-raii 
may  reach  enormous  size. 

Fatty  infiltration  produces  a  moderate,  uniform  eidar<rement 
which  has  a  cushion-like  feel.  The  normal  shape  is  mudtered.  the 
lower  ribs  do  not  tiare.  Ascites  is  not  a  .sequence  and  the  superficial 
veins  are  unaltered.  The  organ  reaches  the  umbilicus  and  the  edge  is; 
rounded  and  ill-defini'd :  pain  ami  tenderness  are  lacking. 


Fig.  68 — The  Liver — NonnnI  area  of  percussion   dullness.     The  apc.x  impact  is 

at  h. 


Drupsical  injillruliiiii  accompanies  general  diopsy  such  as  wa.s 
described  under  dropsical  effusions. 

Amyloid  liver  reaches  a  size  only  surp;issed  hy  cancer  of  Ihe 
organ.  The  enlargement  is  uniform  in  all  directions  and  painless. 
It  is  of  slow  growth,  extending  over  two  or  three  years,  and  may  fill 
the  entire  abdominal  cavity.  The  tumor  is  characterized  by  its  density 
and  resistance.  The  edge  is  sharply  defined.  Ascites  almost  never 
occurs.    The  surface  is  perfectly  smooth. 

Hypertrophic  cirrhosis  occasions  jaundice.  The  li^er  is  enlai'ged 
but  the  surface  is  smooth.    Ascites  is  absent. 

Cancer  gives  ri.se  to  nodular  enlargement  of  the  liver,  associated 
with  tenderness,  and  enlargement  of  the  superficial  veins;  jaundice 


PLATE  XXIII. 

The  Volume  of  the  Liver  in  Various  Diseases  (after  Rindtleisch). 
A.     The  diaphragm  displaced  upward  in  carcinoma.     B.     Normal  position  of 
diaphragm.       C.     Line   of  relative  dullness.       D.     Edge  of    liver   in  cirrhosis. 
E.    Normal  liver.     F.  Fatty  liver.     G.    Amyloid  liver.     H.    Cancer,  leukaemia, 
and  adenoma. 


DISEASES  OF  THE  ABDOMEX  285 

and  ascites  are  both  frequent.  The  liver  enlarges  into  the  left 
hypochondrium,  pushes  the  diaphragm  upwards  and  the  free  border 
descends  even  to  the  crest  of  the  ilium.  Cancer  without  nodular  en- 
largements is  recognized  by  the  size  of  the  organ,  the  cachectic  symp- 
toms and  the  jaundice. 

Echinococcus  causes  enlargement  with  elasticity  or  fluctuation  and 
the  hydatid  thrill  may  be  felt  by  the  superimposed  hand  on  tapping 
over  the  enlargement.  The  thrill  is  a  vibrating,  tremulous  movement 
similar  to  that  obtained  by  tapping  upon  a  bag  of  jelly. 

Lymphadeiiomata  and  lymphomatous  nodules  occiu-  in  the  liver 
in  the  course  of  leukjemic  lymphadenomata.  in  typhoid  fever  and 
other  infectious  diseases. 

Atrophic  cirrhosis  of  the  liver  gives  rise  to  hjemorrhages.  abdom- 
inal dropsy  which  is  profuse  and  quickly  recurs  after  reduction,  and 
oedema  of  the  extremities.  The  caput  Medusie  is  developed.  Jaundice 
is  absent.  The  area  of  Hver  dullness  may  be  determined  by  placing 
the  patient  upon  the  left  side,  so  that  the  dropsical  accumulation  ^vill 
gravitate  away  from  the  hepatic  region.  The  intestines  wiU  float  up 
and  indicate  by  the  characteristic  tj-mpanitic  note  the  boundary-  of 
the  liver.  ITsuaUy  the  dullness  stops  about  an  inch  above  the  lower 
thoracic  border  and  extends  no  farther  than  the  median  line  in  front, 
instead  of  into  the  left  hypochondrium. 

After  paracentesis  the  flaccid  condition  of  the  walls  allows  \ls 
to  palpate  the  surface  of  the  organ,  which  will  be  found  to  be  rough 
and  studded  with  small  nodules. 

Simple  atrophy  shows  diminution  in  size  of  the  organ,  the  sur- 
face remaining  smooth,  ascites  being  absent. 

Acute  yellow  atrophy  gives  origin  to  few  characteristic  sjTuptoms. 
The  disease  progresses  with  gi-eat  rapidity,  so  that  in  a  few  days  the 
area  of  liver  dullness  may  be  entirely  wanting.  The  acute  symptoms 
are  those  of  a  severe  gastro-intestinal  catarrh,  jaundice,  followed  by 
abdominal  pain,  delirium,  coma,  haemorrhage,  from  mucous  mem- 
branes and  even  the  skin.  These,  and  the  rapid  course  of  the  disease, 
are  characteristic  phenomena. 

Syphilis  may  appear  as  atrophic  cirrhosis  resulting  in  irregular 
lobulated  eoptraction  more  characteristic  than  the  non-specific  cirrho- 
sis :  as  gummata.  followed  by  cicatrices,  or  as  diifuse  connective  tissue 
hyperplasia. 


286  DISEASES  OF  THE  Alil>i).MEX 

Di/}'(r(  nlial  I)ia<)ii(isis.  Coiulitions  which  niiiy  lead  to  tlie  orror 
that  the  liver  is  the  seat  of  disease  are: 

(a)  Displacements  of  the  ovfian  hy  diseases  of  the  ri-^ht  side  of 
the  chest,  as  extensive  pleuritic  eft'iisiou  and  pneumo-thorax.  Here 
we  have  the  synii)tonis  of  these  diseases  to  account  fully  for  the 
change. 

(b)  Ftrcal  aceuniulations  in  tiie  ascendinji'  and  transverse  colon; 
which  are  by  no  means  easy  to  exclude  as  they  give  rise  to  a  tnmor 
below  the  edge  of  the  ribs  and  the  area  of  flatness  and  resistance  seems 
to  be  continuous  both  to  palpation  and  to  percussion.  The  lack  of 
elasticity  and  the  indentations  produced  by  palpation  are  aids.  In 
case  of  doubt,  enema  and  pni-gatives  remove  the  source  of  error. 

(c)  Enlargement  of  the  right  kidney.  When  this  organ  increa.ses 
considerablj-  in  size  it  maj-  extend  to  the  under  surface  of  the  right 
lobe  of  the  liver.  By  placing  the  i)atient  on  his  back  and  relaxing 
the  abdominal  walls  the  finger  tips  feel  the  apex  of  the  kidney  sloping 
downward  and  inward  instead  of  outward  and  upward,  and  the  fin- 
gers may  pass  vertically  between  the  borders  of  the  two  organs. 

(d)  Cancer  of  the  stomach  is  movable,  its  note  is  dullness  nvcr- 
lying  tympany  and  the  two  areas  do  not  fuse. 

(e)  Enlargements  of  the  spleen  are  told  by  Ihc  shape,  the  posi- 
tion and  the  inei-easing  flatness  which  obtains  as  we  approach  the 
normal  area  of  the  organ. 

THE  SPLEEN. 

Except  in  so  far  as  it  iiarticijiates  in  the  maladies  miuinatcd  by 
other  organs,  the  spleen  is  sub.jeet  to  but  few  diseases,  and  owing  to 
the  comparative  isolation  of  its  situation,  as  well  as  what  may  be  called 
its  physiologic  exclusiveness,  these  give  rise  to  but  few  symptoms 
which  serve  to  attract  attention  to  the  gland.  For  these  reasons  diag- 
nosis of  its  morbid  conditions  often  presents  si-eater  difficulties  than  is 
the  case  with  any  other  abdominal  organ. 

Siliinlio)!.  This  organ  occupies  the  upper  portion  of  the  left 
hypochondrium.  It  is  not  palpable  in  its  natural  state  and  lies  deeply 
imbedded  between  the  fundus  of  the  .stomach  and  the  diaphragm  in 
the  axillary  line.  Its  outer,  phrenic  or  convex  surface  rests  against 
the  convex  arch  of  the  diaphragm,  which  separates  it  from  the  thoracic 
wall  below,  while  the  uj)per  poi-tion  of  this  same  .surface  is  .separated 
therefrom  hy  the  fnrthci-  intei'position  of  the  pleura  and  to  a  slight 


DISEASES  OF  THE  .UBDOMEN 


■287 


extent  the  edge  of  the  lung.  The  external  sui'faee  extends  from  the 
eighth  to  the  eleventh  rib.  Its  long  axis  is  oblique  and  its  direerion 
and  position  nearly  that  of  the  tenth  rib.  In  front  lies  the  stomach 
and  colon ;  to  its  inner  side  it  is  also  in  relation  to  the  stomach  as  well 
as  to  the  pancreas  and  left  kidney.  Vertically  it  lies  between  the 
ninth  thoracic  spine  and  the  first  lumbar  spine.  Its  inner  extremity 
is  within  two  inches  of  the  mid-dorsal  line.     Its  outer  extremity  is 


AORTA 


Hft6us 


'""   -  Slip.  MESEflTEMt 


Fig.   69 — The  Relation  of   tlie   Spleen   to   the   left  kidney.   The  figures   refer   to  ■ 
the   ribs. 


behind  the  mid-axillary  line.    A  line  drawn  from  left  sterno-clavicular  ■ 
junction  to  the  tip  of  the  eleventh  rib  bounds  it  anteriorly. 

Percussion  area.  To  ascertain  its  boundaries  place  the  patient 
on  the  right  side.  The  anterior  border  is  readily  determined  by  the 
contrast  between  splenic  dullness  and  the  tympany  of  the  stomach  and 
intestines.     Above,  the  limitation  is  determined  by  reaching  pulmon- 


288  DISKASES  OF  TIIK  AUDHMKN 

ary  resouauce.  Below,  where  the  spleen  aud  kidney  ai-e  in  eoniaci  it 
is  impossible  to  separate  the  two  by  percussion.  Tlie  area  thns  deti-r- 
mined  is  about  four  inches  long  and  three  wide. 

The  spleen  may  be  increased  in  size  by  disease,  and  atrophy  is 
possible  but  would  probably  pass  unrecognized  in  life.  It  is  subject 
to  acute  swellings  in  the  course  of  fevers  and  is  ehroiiieally  enlarged 
in  the  following  conditions: 

Congenital  syphilis,  and  in  acquired  syphilis  when  ■nnyldid  d<'- 
generation  attacks  the  organ;  in  alcoholic  cirrhosis  and  in  llanofs 
hypertrophic  cirrhosis ;  when  it  is  the  subject  of  tuberculous  lesions  as 
occasionally  happens;  in  anthrax,  as  evinced  liy  the  older  name  for  the 
malady — splenic  fever.  In  these  forms  and  in  Hodgkin's  disease  and 
lymphatic  leuka?mia  the  spleen  is  moderately  enlarged.  In  rickets  it 
is  often  palpable.  The  organ  is  greatly  enlai-ged  in  spleno-medullary 
leukaemia  aud  iu  palludism,  in  which  its  size  takes  second  rank.  In 
typhoid  fever  it  is  considerably  enlarged  at  the  end  of  the  firsi  wci'k 
and  is  palpable  unless  pushed  back  under  the  diaphragm  liy  a  dis- 
tended colon,  in  which  ease  the  noi'mal  area  of  dullness  may  he  les- 
sened or  even  disappear.  In  death  after  tlie  fourth  week.  atro|)hy 
of  the  spleen  is  not  rare. 

Enlargements  of  the  spleen  are  smooth,  uniform  aud  solid,  willi- 
out  either  pain  or  tenderness.  The  oblong  mass  is  felt  directls  undrr 
the  integument  extending  from  mider  the  ribs  on  the  left  side  forward 
towards  the  median  line,  which  it  may  reach,  or  downward  towards 
the  crest  of  the  ilium,  and  can  scarcely  be  mistaken  or  overlooked. 

The  upper  edge  is  rounded,  the  lower  sharp  and  the  notch  or 
fissure  may  be  apparent.    The  tumor  is  somewhat  movable. 

The  tumors  which  might  be  mistaken  for  enlargements  of  the 
spleen  are  enlargement  of  the  left  lobe  of  the  liver,  fo'cal  accumula- 
tions, ovarian  disease,  enlargement  of  the  left  kidney  and  possibly 
cancer  of  the  cardiac  end  of  the  stomach.  The  first  can  be  distin- 
guished by  tracing  the  organ  across  the  median  line  to  the  right 
hypochrondrium  where  it  connects  with  the  right  lobe.  The  differ- 
ential points  of  the  second  have  been  named.  The  character  of  ovarian 
tumors  will  be  considered  hereafter.  The  left  kidney  may  enlarge 
forward  towards  the  left  hypochrondrium  and  assume  a  position  anal- 
ogous to  that  of  the  spleen,  but  the  tumor  may  be  traced  backward 
into  the  loin,  where  will  be  found  its  chief  bulk,  and  is  much  more 
-fixed. 


DISEASES  OF  THE  .VBDOilEX  289 

Tumors  of  the  spleen  enlarge  forward  and  whenever  the  enlarge- 
ment is  considerable,  project  from  under  the  ribs  and  fall  forward 
when  the  patient  is  placed  in  the  knee-breast  position.  Cancer  of 
the  stomach  could  not  readily  be  mistaken  for  splenic  enlargement 
unless  attachments  had  formed,  which  is  unlikely.  The  dull  note 
overhang  large  tjonpany  on  deep  percussion  aids  in  the  decision. 

THE  KIDNEY. 

The  situation  of  the  kidneys  has  been  given  with  sufficient  ac- 
curacy in  the  section  upon  medical  anatomy.  The  right  is  in  relation 
above  with  the  liver,  below  with  the  caecum,  anteriorly  with  the 
ascending  colon,  behind  with  the  diaphragm.  The  left  is  in  relation 
above  with  the  spleen,  in  front  and  below  with  the  colon,  behind  with 
the  diaphragm. 

It  is  by  no  means  a  simple  matter  to  determine  by  percussion  the 
normal  outlines  of  the  kidneys  in  well-developed  muscular  or  corpu- 
lent individuals,  much  less  to  ascertain  diminution  of  their  volume. 
By  palpation  and  percussion  the  normal  areas  are  obtainable,  and  in 
spare  sub.jects  and  persons  with  well-relaxed  abdominal  walls  they 
may  be  ascertained  with  considerable  accuracy.  In  enlargement  of 
the  organs  the  task  is  sometimes  easier. 

Inspection  rarely  furnishes  any  evidence. 

Palpation  from  behind  is  often  negative:  in  enlargements  the 
external  borders  may  be  felt  to  pro.ject  beyond  the  free  edge  of  the 
quadratus  lumborum.  When,  however,  the  patient  is  supine,  one 
hand  being  placed  in  the  lumbar  region,  with  the  other  pressed  firmly 
downward  and  inward  the  organ  is  felt,  and  if  enlarged  the  tumor 
may  be  pressed  backwai'ds  and  by  bi-manual  palpation  its  size,  situa- 
tion, consistency  and  possibly  its  nature  determined. 

Percussion.  The  position  of  the  patient  should  be  prone,  which 
allows  the  intestines  to  float  upward,  the  spleen  and  liver  to  project 
forward,  and  any  accumulation  of  fluid  which  may  be  present  to 
gravitate  away.  The  external  margins  are  indicated  by  a  tympanitic 
note.    Inwardly  the  dullness  coalesces  with  that  of  the  vertebrae. 

Enlargements  will  increase  the  lateral  area  of  dullness. 

Absence  of  one  kidney  is  frequently  observed.  The  opposite 
organ  may  be  hypertrophied. 

Displacement  of  the  kidney  is  congenital  or  acquired.     The  dis- 


lilHI  niSEAiSKS  OK  TUE  ABDOMEN 

l>l;K'i'iiuMit  iiiMv  lie  in  any  direction;  most  fi-0(|uoiitly  it  is  into  the 
IH'his, 

Adiuired  malpositions  are  ol'tenest  met  with  in  women  after 
repeated  prejnianeies,  or  caused  by  tight-laciutr,  diseases  and  displace- 
ments of  the  liver.  The  right  is  more  frequently  displac-r,!  than  the 
left. 

When  the  elongation  of  the  peritoneal  rerteetion  is  such  that  the 
Icidney  descends  into  the  abdominal  cavity,  it  maj'  be  readily  felt 
through  the  anterior  abdominal  wall  by  placing  the  patient  on  the 
back  with  the  thighs  flexed,  grasping  the  tumor  in  the  palm  of  the 
hand.  The  normally  dull  area  in  the  lumbar  region  is  replaced  by 
tympany.  The  organ's  size,  shape  and  smoothness  distinguish  it 
from  mesenteric  tumors.  When  pressed  upon  it  glides  away  into  the 
abdominal  cavity  and  wholly  disappears. 

The  kidneys  are  enlarged  in  active  and  passive  hypenijmia,  in 
cedema,  in  acute  diffu.se  and  acute  catarrhal  nephritis,  but  in  none  of 
these  is  the  increment  possible  of  detection  by  the  physical  signs.  In 
hypertrophic  and  amyloid  kidney,  in  which  disorders  the  organ  may 
be  enlarged  to  twice  its  normal  bulk,  the  enlai-gement  should  be  de- 
tected. Sarcoma,  carcinoma,  calculus  pyelitis,  hydronephrosis,  cystic 
dilatation  due  to  obstruction,  or  congenital  cysts,  the  latter  affecting 
both  kidneys,  are  of  large  size,  and  the  tumor  readily  diagi  osed. 
Echinococcus  cysts  are  rare. 

THE  BLADDER. 

When  empty  the  bladder  reposes  behind  the  symphysis  and  c;ui- 
not  be  detected.  When  distended  it  rises  above  the  pubes  and  a  visible 
tumor  appears  in  the  hypogastrium,  which  is  elastic,  smooth  and  mod- 
erately hard  on  palpation.  On  percussion  its  dome-like  ai'ea  is  easily 
determined  by  its  flat  note  contrasted  with  the  tympany  of  the  intes- 
tines in  contact  with  it.  In  children  the  bladder  is  normally  higher 
than  in  adults  and  can  be  detected  even  w-hen  partially  filled.  In 
females  an  ovarian  tumor  or  an  enlarged  uterus  might  be  mistaken 
for  a  distended  bladder,  but  the  catheter  would  resolve  the  doubt. 

THE  UTERUS. 

The  normal,  unimpregnated  uterus  is  situated  deep  in  the  hypo- 
gastrium and  is  inaccessible  to  external  palpation  or  percussion. 

When  enlarged  from  any  cause  its  boundaries  are  determined  by 


DISEASES  OF  THE  ABDOMEN  291 

these  methods  Avith  readiness  aud  exactness:  and  when  impregnated 
auscultation  furnishes  us  with  confirmatory  evidence.  Pregnancy 
cannot  be  differentiated  from  other  smooth,  uniform,  progressive 
enlargements  of  the  uterus  by  palpation  or  percussion,  yet  the  shape' 
of  the  enlargement  is  nearly  if  not  quite  distinctive.  The  pregnant 
uterus  is  egg-shaped  with  the  large  end  up,  while  bhe  swelling  of 
ascites,  which  gives  to  the  abdomen  a  similar  appearance  when  the 
patient  is  erect,  with  the  patient  on  the  back,  is  flat,  the  flanks  flaring. 
Tumors  of  the  womb  are  seldom  symmetrical  and  regular.  Ovarian 
tumors  are  spherical. 

After  the  fourth  month  of  pregnancy  is  past  adventitious  sounds 
are  to  be  heard  on  auscultation  of  the  uterus  containing  a  living 
fcEtus,  viz:  The  placental  bruit  and  the  fcetal  heart  sound.  The 
patient  is  placed  upon  the  back  with  the  thighs  flexed,  the  abdomen 
uncovered.  With  the  stethoscope  different  areas  are  carefully  and 
attentively  examined  until  the  presence  or  absence  of  the  sound  is, 
determined.  The  areas  over  which  they  are  heard  are  circumscribed 
and  their  intensity  is  not  great,  hence  care  must  be  exercised  lest  they 
be  overlooked. 

The  placental  bruit  may  be  heard  at  an  earlier  period  than  the 
fcetal  pulse.  It  is  an  intermittent,  blowing  sound,  single,  and  was. 
_ called  the  bruit  de  souffle,  or  bellows  murmiu',  by  its  discoverer,  M.. 
Kergaradec  (1823).  It  is  sometimes  hissing.  In  time  it  is  synchro- 
nous with  the  maternal  pulse.  It  varies  in  character  and  is  sometimes 
present  and  disappears  at  others.  Also  its  seat  and  the  areas  over 
which  it  is  heard  vary  in  different  cases.  Delens  asserts  that  it  can  be 
heard  as  early  as  the  third  month.  During  labor  its  intensity  is 
greatly  increased.  A  similar  bruit  is  sometimes  present  in  uterine  and 
ovarian  tumors. 

The  foetal  heart  sounds  have  long  been  likened  to  the  ticking  of  a 
watch  enveloped  in  a  napkin.  They  may  be  heard  in  the  course  of  the 
fourth  or  fifth  month  (Cazeaux).  The  pulsations  are  double,  short, 
and  rapid  and  vary  from  130  to  160  per  minute.  The  two  sounds- 
vary  in  intensity,  the  second  being  the  clearer,  more  sonorous  and 
more  distant.  They  are  most  often  audible  on  the  anterior,  inferior 
abdominal  wall,  just  above  the  iliac  fossa,  but  the  location  varies. 
Twin  pregnancies  may  occasionally  be  foretold  by  hearing  the  heart 
sounds  at  distant  points  over  the  tumor  and  by  the  absence  of  syh- 
chi'onism  in  the  two  sounds.  The  pulsations  of  the  maternal  arteries. 


2!»2  mSKASKS  OF  TIIK  AKDOMKX 

could  Ik'  iiiistiikcii  tor  the  int  rii-iitcriiic  sounds  (inly  when  ihi'  pulsr  is 
abnormally  I'apid,  and  even  then  the  quality  would  materially  ditl'er. 
When  inaudible  in  one  position  the  i'(etal  sound  may  be  heai-d  by 
chaufrinfT  the  position  of  the  mother.  Total  cessation  al'Irr  haxins; 
been  present,  indicates  the  death  of  the  fd^tus. 

TiniKirs  iif  llii  ri(  nis.  These  occupy  the  same  area  as  the  uterus 
enhirui'd  by  jireLjiuincy.  'i'lieir  outline  can  be  established  by  pal|)ation 
and  percussion,  'i'hi'  peculiar  hai'dness  and  clasl  irit  \',  tlu'  position  ami 
shape.  I'cadily  estal)lisli  theii'  connect  ion  willi  the  womb.  Doubt  is 
dispelled  by  external  jialpatiou  and  the  use  oT  the  uterine  sound. 
Ii-resular  and  nodular  growths  can  be  fell  throujih  the  abdominal  wall. 

Ofariiiii  Tidiiors.  The  ovaries,  like  the  bladder  and  the  uterus, 
in  the  normal  state  jiive  no  evidence  of  their  existence  to  external 
palpation.  "When,  however,  they  become  enlai\aed  by  disease,  they  rise 
from  the  pelvis  into  the  abdominal  cavity  and  theii-  outline  becomes 
apparent  on  pal|)atioii.  Percussion  gives  a  sharj.  line  of  demarcation, 
owing  to  the  growth  being  sui'roiinded  by  intestines.  When  ovarian 
growths  reach  enormous  size  they  occupy  the  entire  anterior  abdominal 
cavity,  pu.shing  the  intestines  backward  and  upward  into  the  dome  of 
the  diai>liiagni  ;ind  raising  that  stnieture  to  its  highest  possible 
stretching  point.  When  small  and  fir.st  attract  the  attention  of  the 
l)atient  they  may  be  confined  to  one  or  the  other  iliac  region,  but 
oftenest  they  are  central  when  first  ob.served.  They  are  of  frequent 
wccurrenee,  and  as  the  medical  man  is  most  often  first  sought  for 
advice,  a  few  salient  points  npon  their  diagnosis  is  not  amiss. 

If  the  tumor  has  not  risen  from  the  pelvis  a  bi-manual  examina- 
tion w'ill  reveal  that  the  growth  is  lateral  and  not  central ;  and  if  the 
former,  the  notch  or  interval  which  sepai-ates  it  fi'om  the  uterus  is 
felt.  By  palpation  and  the  aid  of  the  sound  the  independent  mobility 
of  the  two  is  established.  The  sound  shows  increase  in  the  depth  of 
the  uterine  cavity  in  tumors  of  that  organ,  which  is  absent  in  ovarian 
disease. 

When  the  tumor  has  risen  into  the  abdominal  cavity  inspection  in 
the  earlier  stages  shows  the  uneven  and  unsymmetrical  development 
of  the  tumor  due  to  its  occupying  the  iliac  or  lumbar  region  of  one 
side,  whence  it  grows  towards  the  umbilicus.  Later,  when  the  entire 
abdomen  is  occupied,  the  tumor  projects  as  a  smooth,  spherical,  fairly 
symmetrical  swelling  which  diit'ers  from  the  central  rounding  of  preg- 
Bancv  and  from  ascites  in  the  manner  stated. 


DISEASES  OF  THE  .VBDOilEX  293 

Palpation.  Small  ovarian  growths  are  firm  and  elastic,  the  large 
ones  fluctuating  and  soft.  When  only  a  portion  of  the  abdomen  is 
occupied  by  the  tumor  its  outline  can  be  determined  by  palpation  and 
perciission.  The  sense  of  fluctuation  varies,  increasing  with  the  size, 
but  is  usually  quite  distinct  in  all  cases. 

Percussion  gives  a  flat  sound  over  the  area  occupied  by  the  tumor. 

with  t^i-mpanitic  resonance  over  the  areas  occupied  by  the  intestines. 

Diagnosis.     The  differentiation  of  ovarian  dropsy  from  ascites  is 

easy,  yet  confusion  frequently  arises.    Hence  the  following  distinctive 

points  are  noteworthy. 

Inspection.  Ovarian  tumors  project  forward  and  are  rounded 
and  central  whatever  be  the  position  of  the  patient.  In  ascites  the 
form  changes  with  the  position ;  when  the  patient  lies  on  the  back  the 
enlargement  is  uniform  and  the  abdomen  is  flattened. 

Percussion  made  in  the  supine  position  gives  dullness  over  the- 
surface  of  an  ovarian  tumor,  while  in  ascites,  because  the  intestines 
float  on  the  fluid,  the  re.sonance  is  tvnnpanitie  aboce  and  duU  as  high  as 
the  fluid  extends. 

Change  of  pos-ture  alters  the  area  but  little  in  ovarian  dropsy  but 
markedly  alters  it  in  general  dropsy. 

These  points  and  the  evidence  of  cardiac,  renal  or  hepatic  disease 
to  account  for  the  ascites  should  enable  one  to  decide  the  question. 
Renal  cysts  push  the  intestines  forward,  not  backward ;  and  pus.  blood 
and  albumin  appear  in  the  urine.  They  grow  slowly  from  above 
downward,  and  when  pushed  up  resonance  appears  between  the  tumor 
and  the  pelvis.  The  same  points  apply  to  splenic  and  hepatic  cysts. 
To  mistake  pregnancy  for  ovarian  cyst  would  be  inexcusable  careless- 
ness. It  should  be  borne  in  mind  that  either  may  arise  in  the  case 
of  unmarried  females. 

For  additional  points  upon  the  diagnosis  of  ovarian  cysts  from 
cysts  of  the  broad  ligament  and  from  uterine  fibro-cysts,  the  reader  is 
referred  to  works  on  gjTiffcologj". 

The  omentum  may  be  the  seat  of  tuberculous  disease  and  deposit, 
of  sarcoma,  cancer  and  of  hydatid  cysts.  The  thickening  and  nodular 
enlargements  are  easily  felt  through  the  abdominal  walls  in  cancer 
and  may  often  be  seen.  They  give  rise  to  a  dull  area  on  percussion  in 
the  upper  zone  of  the  abdomen  which  increases  with  their  growth 
from  above  downward,  and  unless  extensively  adherent  they  may  be 
pushed  iipwards.     The  growths  are  superficial  and  generally  tender. 


294  DISEASES  OF  THE  ABDOMEN 

Cancer  and  tnbd-rulnsis  of  tlir  (iiiu'iituiu  .i;ive  rise  to  ascites  and 
the  general  symptoms  ol'  the  diseases.  In  a  case  of  cancer  occurring  in 
my  own  practice,  small,  hard  nodules  were  early  detected  in  the  omen- 
tnu).  which  gave  the  sensation  on  paljiation  of  small  cliips  of  wood 
laid  upon  the  intestines. 

Percussion  in  cancer  is  wooiUike.  ovei-lying  tympany,  until  the 
fluid  accumulates. 

ASCITES. 

An  accumulation  of  sei-ous  fluid  free  within  the  abdominal  cavity 
is  termed  ascites. 

The  causes  are  local  and  general. 

Local  causes  are:  Intlannnations  of  the  peritoneum,  simjile  or 
tubercular;  cancer  of  the  peritoneum. 

Obstruction  of  the  portal  circulation  within  the  liver,  as  in 
cirrhosis  and  chronic  passive  congestion,  or,  in  the  branches  of  the 
gasti'o-hepatic  omentum  by  new-growths,  peritonitis  or  aneur.ysni. 

Pressure  upon  other  vessels,  as  in  the  ascites  associated  with 
ovarian  dropsy,  due  to  pressure  exerted  hy  the  growth. 

A.seites  accompanying  enlargements  of  the  spleen. 

(leneral  causes  are  those  which  produce  general  anasaica,  and 
include  organic  heart  and  lung  diseases,  chronic  Bright 's  disease,  and 
hj'drajmia.  Here  the  cause  may  operate  directly  or  mechanically.  In 
heart  disease,  when  ascites  occurs  without  general  cedema,  secondary 
changes  in  the  liver  should  be  sought  for.  Pulmonary  emphysema 
and  cirrhosis  of  the  lung  exhibit  ascites  as  terminal  symptoms.  The 
various  kidney  lesions  associated  with  ascites  have  been  mentioned. 

Inspection.  The  abdomen  is  uniformly  enlarged,  and  when  the 
patient  lies  on  the  back  the  flanks  flare  outward.  The  umbilicus  is 
prominent  and  protrudes  on  standing.  In  old  and  recurrent  cases  the 
linese  albicantes  show.  In  cirrhosis,  the  superficial  veins  are  prom- 
inent and  the  caput  Medusffi  may  be  present  (see  Liver  Diseases). 

Palpation.  Fluctuation  is  easily  felt  by  placing  one  hand  over 
the  lateral  area  and  smartly  tapping  on  the  opposite  side.  The  fluctu- 
ation is  more  apparent  if  the  patient  sharply  depresses  the  linea  alba 
with  a  thin  book  or  cardboard. 

Small  effusions  are  palpable  hy  placing  the  patient  in  the  knee- 
breast  position .  when  the  fluid  gravitates  to  the  dependent  part  and 
floats  the  intestines  away.     In  case  of  large  effusions  difificulty  may 


DISEASES  OF  THE  ABDOilEX  295 

be  experienced  in  palpating  the  abdominal  organs.  This  may  be  over- 
come by  suddenly  deeply  indenting  the  walls  with  the  finger-tips  in 
the  desired  locality,  in  order  to  displace  the  tluid.  In  eases  of  consid- 
erable tension  even  this  fails. 

Percussion.  The  area  of  dullness  surrounds  the  t^nnpauitic  area 
of  floating  intestines  when  the  patient  is  in  tlie  dorsal  position,  hence 
the  lateral  areas  are  dull,  and  the  height  of  the  dullness  rises  as  the 
fluid  increases.  The  line  separating  dulbiess  and  tympany  is  sharply- 
defined,  and  when  marked  oiit  is  ovoid  in  shape. 

The  dullness  is  movable.  When  the  patient  is  placed  on  the  side 
the  region  of  the  upper  flank,  pre^aously  dull,  becomes  tympanitic. 
EfEusions  too  small  to  give  rise  to  dullness  with  the  patient  on  the 
back  are  easily  discovered  by  placing  Mm  in  the  knee-breast  position. 

The  diagnosis  of  ovarian  ascites  from  free  peritoneal  ascites  has 
been  given.  The  principal  diagnostic  point  is  the  recognition  of  the 
causative  condition.  The  heart  and  lungs  show  positive  signs  of  dis- 
ease when  the  dropsical  stage  is  reached,  and  the  dyspncea  is  out  of 
proportion  to  the  pressure  caused  by  the  fluid.  The  liver  shows 
enlargement  and  the  superficial  veins  are  its  sign-board.  The  lu-ine 
gives  evidence  of  Bright 's  disease.  Cancer  of  the  omentum  can  be 
felt  as  lumpy  enlargements  directly  under  the  sMn.  Fever,  hectic, 
wasting  and  night-sweats  point  to  tuberculosis.  Percussion  shows  en- 
larged spleen.  Blood  examination  demonsti-ates  its  relationship  to 
the  condition. 


SECTION  XIV. 

EXAMINATION      OF      THE     STOMACH 
CONTENTS. 

Introduction.  The  gastric  fluid  is  a  thin,  almost  colorless  liquid, 
acid  in  reaction,  with  a  sp.  gr.  of  1001  to  1010.  The  analysis  varies 
greatly  with  different  conditions  and  different  observers.  The  fol- 
lowing is  approximate  (Schmidt)  : 

Water 994.4 

Organic  substances,  pepsin 3.2 

Hydrochloric   acid    0.2 

Sodium  chloride   1.5 

Potassium  chloride 0.5 

Other  inoruranie  salts 0.2 


1000. 


The  total  acidity  varies  between  0.10  aud  O.IJO.  The  free  acid 
varies  between  0.10  and  0.30,  normally  only  reaching  the  latter  point 
on  a  carbo-hydrate  diet.  Ordinarily  on  nitrogenous  diet  it  does  not 
exceed  the  minimal  figure. 

The  secretion  of  gastric  juice  begins  immediately  upon  the  inges- 
tion of  food  but  the  hydrochloric  acid  contained  in  the  first  portions 
secreted  combines  rapidly  with  the  ingested  proteids  and  their  con- 
tained inorganic  salts,  the  product  being  acid  proteids  and  acid  salts. 
The  chief  mineral  salts  are  the  di-sodic  and  di-potassie  phosphates, 
which  are  converted  into  the  corresponding  acid  pho.sphates.  For  this 
reason  free  hydrochloric  acid  is  not  found  in  the  stomach  contents 
until  a  vai-ying  time  after  eating,  depending  upon  the  character  and 
amount  of  food  ingested.  After  an  ordinary  meal,  free  acid  appears 
in  healthy  stomachs  in  from  forty-five  minutes  to  one  hour,  and  ihe 
amount  gradually  increases  as  digestion  proceeds,  reaching  its  height 
towards  the  conclusion  of  gastric  conversion. 


EXAMINATION  OF  THE  STOMACH  CONTENTS  297' 

Fats  and  starches  in  superabundance  delay  its  appearance.  After 
the  Ewald  test-meal  free  acid  should  appear  in  twenty  minutes. 

With  ordinary  diet  lactic  acid  is  very  generally  found  in  the 
stomach  contents  in  small  amounts,  and  under  certain  circumstances 
butyric  and  other  organic  acids  may  appear,  without  being  manifesta- 
tions of  disease.  In  gastric  catarrh,  anaemia,  during  the  course  of 
fevers,  pepsin  and  hydrochloric  acid  are  considerably  reduced.  Hydro- 
chloric acid  is  increased  in  gastric  ulcer  and  in  nervous  dyspepsia 
(hyperchlorhydria),  and  in  those  queer  cases  of  super-secretion  of 
Reichmann  and  Rossbach  ( gastroxynsis ) . 

Fermentative  changes  may  cause  lactic  and  butyric  acid  to  ap- 
pear in  large  amounts  in  the  fluid,  accompanied  by  gaseous  distention 
and  sour,  gaseous  eructations.  Excessive  mucus  accompanies  catarrhal 
inflammations.  Blood,  bile,  fragrants  of  growths,  albumin,  anunonium 
carbonate  and  urea  occur  in  special  conditions. 

»     The  clinical  examination  of  the  gastric  fluid  is  practically  limited 
to  the  determination  of: 

(a)  The  reaction. 

(b)  Total  acidity. 

(c)  Presence  of  free  acid  and  of  acid  salts. 

(d)  Presence  of  free  hydrochloric  acid. 

(e)  Organic  acids. 

(f )  Presence  of  syntonin,  peptone  and  the  pepsin  strength. 

The  volumetric  analysis  can  be  performed  readily  by  those  pos- 
sessing even  slight  skill  in  laboratory  manipulations.  The  necessary 
apparatus  is  simple  and  inexpensive.  The  standard  or  volumetric 
solutions  are  easily  prepared  or  may  be  purchased  from  competent 
pharmacists. 

The  necessary  apparatus  is : 

A  50  e.  c.  burette,  graduated  to  0.1  c.  c. 

A  graduated  pipette,  and  one  or  two  graduated  cylinders ;  one  or 
two  flasks,  capacity  500  c.e. ;  or  a  litre,  and  necessary  test  tubes. 

EXAMINATION  OF  THE  GASTRIC  CONTENTS. 

The  examination  of  the  gastric  contents  for  clinical  purposes,  such, 
as  ascertaining  the  state  of  the  secretion,  the  motor  function  of  the 
stomach,  the  presence  or  absence  of  abnormal  substances  and  the 
products  of  gastric  digestion,  has  approached  almost  to  a  routine  pro- 
cedure.    After  fasting  all  night,   or,  better,   after  washing  out  the- 


298  EXAMINATION  OF  THE  STOMACH  CONTENTS 

stomach,  the  patient  is  given  a  test-breakfast.  Ewald's  is  simplest 
and  most  used,  consisting  of  an  ordinary  baker's  I'oll  eaten  dry,  and 
300  c.c.  of  weak  tea,  without  milk  or  sugar,  or  a  like  quantity  of  warm 
water.  8ueh  a  "meal"  contains  little  or  no  lactic  acid,  the  presence 
of  which  is  the  objection  to  most  proposed  test-meals.  The  Boas'  test- 
meal,  consisting  of  a  grnel  made  of  a  tablespoonful  of  oatmeal  boiled 
in  a  litre  of  water,  may  be  used  for  estimating  lactic  acid.  One  hour 
after  ingestion  the  residue  is  removed  with  the  stomach  tube  and 
examined.  The  residue  should  be  about  40  c.  c.  After  noting  the 
quantity,  odor,  color,  consistence,  and  amount  of  mucus,  a  small  por- 
tion is  examined  with  the  microscope  to  determine  the  nature  of  Ihe 


Fig.  "O — Stomacli  Tube  willi  Sypl'on  Bulb. 

residue  and  the  presence  of  anatomic  elements.    The  remainder  is  well- 
shaken,  filtered,  and  the  clear  filtrate  tested  as  soon  as  possible. 

Reaction.  The  normal  reaction  of  the  gastric  juice  is  decidedly 
acid,  due  to  hydrochloric  acid,  acid  salts  (NaH„P04),  occasionally  to 
organic  acids  and  carbonic  acid.  During  digestion  free  organic  acids, 
acid  albumins,  consisting  of  combinations  of  hydrochloric  acid  and 
organic  acids  with  the  proteids  of  the  food,  and  the  acid  salts  (acid 
sodium  and  acid  pota.ssium  phosphates)  also  add  to  the  acidity. 
Lactic  acid  should  not  be  present  after  the  oatmeal  breakfast.  Its 
sources  are,  fermentation  of  the  stomach  contents  due  to  retention — 
.defieiencj'  of  the  motor  function  and  to  pyloric  obstruction — and  to 
the  introduction  of  sarcolaetie  acid  into  the  stomach  with  foods. 
Butyric  and  acetic  acid  are  fermentation  products.  In  gastric  carci- 
noma, lactic  acid  is  found  after  the  test-breakfast.     The  reaction  is 


EXAMINATION  OF  THE  STOMACH  CONTENTS 


299 


'determined  with  litmus  paper  which  acids  turn  red.    Other  substances 
used  as  acid  indicators  are : 


Name  of  Dve 

Solvent 

Color 

WITH 
.\CIDS 

Color 

WITH 

.Alkalies 

Reacts 

WITH 

Sensitiveness 

I*  in 
Alcohol 

Colorless 

Pink  or 
Red 

All  .\cids 

Extreme 

Water 
It  Sol. 

Blue 

Claret 

Free  .\cids 
Only 

HC1=  o.iiniooo 

Lactic— 0.2  in  looo 

Water 

Red 

Yellow 

H  CI  =  0.3  in  1000 
E.xtreme 

Litmus 

Water 

Red 

Blue 

All  Acids 

Dimethyl-amido-azobenzol 

0.;  ■  in 
.Alcohol 

Cherry 

Yellow 

Free 
Mineral 
Acids 

H  CI  =  0.2  in  1000 

Alizarin-sulphonate  of  sodium  .... 

Water 
r:i  Sol. 

Yellow 

Violet 

Free  Acids 

and 
Acid  Salts 

H  CI  =0.2  in  1000 

Boas'  resorcin  sol.,  Resorin,  5  gm.\ 
cane  sugar,  3gra.;  alcohol,  (95vc), 

Alcohol 

Pink 

Colorless  ' 

Free 
Mineral 
Acids 

H  CI  =0.5  in  1000 

Gunzburg's     Solution.        Phloro- 
glucin,   2  gm.;    vanillin,   i   gm.; 
.Mcohol  (95^w ,  100  c.  c 

Alcohol 

Pink 

Light 
Brown 

Free 
Mineral 
Acids 

HCI  =  o.5iniooo 

Dried  papers  colored  with  the  above  solutions  are  convenient  for 
testing.  Bj'  testing  the  filtered  gastric  contents  .successively  with 
three  papers  colored  with  the  above  dyes,  we  may  determine  whether  it 
is  acid  (litmus)  ;  whether  the  acidity  is  from  free  acid  (congo-red)  ; 
and  whether  free  hydrochloric  acid  is  present  (azobenzol).  If  the 
congo-red  paper,  blued  by  free  acid,  is  gently  warmed  the  blue  color 
is  discharged  when  it  is  due  solely  to  organic  acids,  but  remains  if  pro- 
■duced  by  hydrochloric  acid.  Boas'  resorcin  solution  is  more  stable 
than  Gunzburg's  solution,  and  equally  sensitive.    It  is  used  thus: 

A  few  drops  of  the  reagent  are  spread  upon  a  porcelain  dish, 
which  is  gently  heated ;  a  glass  rod  dipped  in  the  gastric  fluid  is  drawn 
across  the  field.  Free  hydrochloric  acid  causes  a  scarlet  streak  to  ap- 
pear. If  the  acid  is  present  in  small  quantity  the  streak  appears  only 
■on  complete  evaporation.  Previous  filtration  is  not  necessary.  Pro- 
teids,  acid  salts  and  organic  acids  do  not  interfere  with  the  test.  One 
part  of  hydrochloric  acid  in  20,000  parts  of  water  is  detected  by  the 
method. 

Organic  Acids. — The  sources  of  lactic,  acetic  and  butyric  acid 
."have  been  mentioned.     The  presence  of  more  than  a  trace  of  organic 


300  EXAMINATION   OK    TIIK  STOMACH    CONTENTS 

acid  in  tlu'  stoinai'li  at'ti'i'  the  li'sl-inral  sIkhiKI  \n-  rfi^arilcd  as  patho- 
losric.  Butyric  acid  ha.s  an  odor  like  that  of  rancid  butter  and  cau 
trencrally  be  detected  by  the  smell.  Acetic  acid  has  a  vinegar-like 
odor,  which  is  emphasized  by  boilinjr. 

The  tests  may  be  applied  to  the  mixed  tiuid  or  the  oriranic  acids, 
may  be  extracted  with  ether. 

Method:  5  c.  c.  of  the  grastric  fluid  are  boiled  with  thi'ce  drops  of 
hydrochloric  acid  until  syrupy  in  consistence.  After  coolinsi  add  a 
small  quantity  of  ether,  shake  well,  decant  into  a  basin,  add  ether 
again  and  repeat.  The  ether  is  evajioi^ated.  the  n'siduc  irdissdlvi'd  in 
a  few  drops  of  water  and  tested. 

The  most  important  of  tlie  organic  acids  is  lactic  acid  and  it 
occurs  in  larger  amount  and  more  frequently  than  the  others.  As. 
stated,  the  presence  of  organic  acids  results  whenever  the  food  is  too 
long  retained  in  the  stomach,  and  occurs  when  hydrocholoric  acid  is. 
deficient,  in  dilation  of  the  stomach,  deficiency  of  its  motor  func- 
tion, in  cancer  and  in  stenosis  of  the  pylorus. 

The  breakfa,st  of  oatmeal-gruel  contains  no  lactates,  and  is  supe- 
rior to  the  Ewald  meal. 

Tests:  Dilute  solutions  of  fen-ic  chloride  turn  cMiiai-y-yellow  on 
contact  with  lactic  acid  (Uft'elmann's  test).  A  few  droi>s  of  dilute 
neutral  solution  of  ferric  chloride  are  mixed  with  a  Fourth  the 
quantity  of  carbolic  acid,  and  water  added  until  a  clear  amethyst 
color  is  obtained.  Lactic  acid  in  the  proportion  of  1  to  2,000  instantly 
changes  the  blue  color  to  yellow.  Lactates  produce  the  same  result, 
but  as  their  clinical  significance  is  the  same,  it  does  not  interfere  with 
the  test.  Sugar,  alcohol  and  certain  salts,  as  phosphates,  are  capable 
of  changing  the  color.  Butyric  acid.  5  parts  in  1,000,  changes  Uffel- 
mann's  reagent  to  a  tawny-red  color.  The  quantitative  determination- 
of  organic  acids  is  rarely  necessary  for  clinical  purposes. 

(a)     Quantitative  estimation  of  the  total  acidity. 

Method :  10  c.  c.  of  the  filtered  fluid  are  accurately  measured  into- 
a  beaker  and  three  drops  of  the  phenolphthalein  solution  are  added. 
The  burette  is    filled  with  ,-J-  NaOH  solution*   which   is  added    until 


*\Vliich  means  a  decinonnal  solution.  A  normal  solution  is  made  by  dis- 
solving the  molecular  weight  in  grams  of  this  substance  in  a  litre  of  water.  A 
decinormal  solution  is  one-tenth  of  that  strength.  In  the  case  of  NaOH,  401 
grams  to  the  litre  constitutes  a  normal  solution,  but  owing  to  the  impossibility 
of  obtaining  pure  sodium  hydro.xide.  the  solution  must  be  standardized  by  titra- 
tion against  a  normal  solution  of  oxalic  acid  and  corrected  as  follows :  50  grams- 


EXAMINATION  OF  THE  STOMACH  CONTENTS  301 

a  permanent  pink  color  is  produced  in  the  beaker.  Near  the  comple- 
tion of  the  test,  each  drop  produces  a  pink  cloud  which  disappears 
on  stirring  with  the  glass  rod,  until  neutralization  occurs,  when  a  sin- 
gle drop  produces  a  permanent  shade.  The  number  of  c.  c.  of  the 
decinormal  alkaline  solution  used  multiplied  by  .00364  equals  the 
weight  in  grams  of  hydrochloric  acid  in  ten  c.  c.  of  gastric  fluid.  This 
multiplied  by  ten  gives  the  percentage. 

The  decimal  .00364  represents  the  weight  of  HCl.  neutralized  by 
1  c.  c.  of  the  NaOH.  solution. 

(b)  The  estimation  of  free  liydroehlorie  acid. 

Topfers  method :  To  10  c.  c.  of  gastric  fluid  add  three  or  four  drops 
of  a  0.5  per  cent,  alcoholic  solution  of  dimethyl-amido-azobenzol. 
The  decinormal  solution  of  NaOH  is  run  from  the  burette  until  the 
red  color  changes  to  a  pure  yellow.  This  reaction  is  not  affected  by 
combined  hydrochloric  acid  nor  organic  acids,  unless  0.2  per  cent,  of 
lactic  acid  be  present.  The  calculation  is  made  by  multiplication  as 
before. 

The  test  may  be  made  by  using  Boas"  resorcin  solution  if  pre- 
ferred. A  few  drops  of  this  solution  ai-e  spread  on  a  piece  of  ground 
glass  and  dried.  The  |ij  NaOH  soluiion  is  added  from  the  burette 
to  the  10  c.  c.  of  filtered  ga.stric  fluid  minus  the  indicator,  as  before, 
until  a  drop  of  the  solution  removed  with  the  rod  fails  to  react  by  giv- 
ing a  pink  color  when  drawn  across  the  warmed  plate.  Blowing  upon 
the  plate  intensifies  and  hastens  the  color  production. 

(c)  Estimation  of  combined  hydrochloric  acid.  Here  alizarin- 
sulphonate  of  sodium  in  1  per  cent,  aqueous  solution  is  used  as  an  in- 
dicator, which  reacts  with  all  acid  elements  except  acid  albuminates. 

The  alkali  is  added  as  before  to  10  c.  c.  of  gastric  fluid,  colored 
with  three  drops  of  the  indicator,  until  a  clear  reddish-violet  color  is 
attained,  which  is  not  reached  until  free  acid,  acid  salts  and  organic 
OfCids  have  been  nevitralized.  As  the  color  produced  in  the  alizarin 
test  is  not  easily  recognized  by  the  inexperienced,  a  1  per  cent,  solu- 


of  best  NaOH  are  dissolved  in  a  litre  of  water.  loc.c.  of  this  solution  are  placed 
in  a  beaker  and  3  drops  of  the  i  per  cent,  alcoholic  solution  of  phenolphthalein 
are  added  for  an  indicator.  From  the  burette  is  dropped  sufficient  of  the  normal 
oxalic  acid  sokition  (6^  grams  to  i  litre)  to  just  discharge  the  pink  color.  If 
each  solution  were  normal  equal  volumes  would  exactly  neutralize  each  other. 
Suppose  I2C.C.  of  the  acid  were  required,  then  the  NaOH  solution  is  12-10 
strength  instead  of  10-10,  hence  mrst  be  weakened  by  additions  of  the  difiference 
in  c.c.  of  water,  which  is  in  this  case  2-10.  In  other  words  20  c.e.  of  water 
must  be  added  to  every  ipoc.c.  of  the  hydroxide  solution  to  render  it  normal. 


802  K\A.MI,\.VTI()N  OP  TllK  STOMACH   CONTENTS 

tioii  of  sodium  pluisphati'  or  sodium  farlxumti'  may  he  colcii-cd  with  Ihc 
indicator  and  used  for  comparison.  It  will  be  seen  that  the  dift'erence 
between  the  number  of  c.  e.  used  in  this  titration  and  that  used  in 
the  estimation  of  total  acidity  by  the  (a)  phenolphthalcin  method 
equals  the  number  of  c.  c.  necessary  to  neutralize  the  combined  hydro- 
chloric acid.  Hence  by  these  three  tests  we  get  the  total  acidity  (a), 
the  free  acid  (b),  the  combined  acidity  by  subtracting  (c)  from  (a). 
The  organic  acids  and  acid  salts  together  are  found  by  adding  (b)  t<i 
(a)  minus  (c)  and  subtracting  the  sum  from  (a). 

Free  acids,  and  acid  salts.  A  simple  method  dl'  dctcrminini: 
whether  acidity  is  due  to  free  acid  or  to  acid  salts  is  by  the  additicni 
of  calcium  carbonate,  CaCO,.  Free  hydrochloric  acid  decomposes  the 
carbonate  and  is  neutralized,  while  acid  sodium  phosphate,  NafL 
POj,  is  unaffected.  If  therefore  the  acidity  disappeai's  it  was  dud  to 
hydrochloric  acid,  if  diminished,  as  shown  by  the  color  reaction  to 
test-paper,  the  remaining  acidity  is  due  to  acid  salts.  The  test  may 
also  be  used  quantitatively  by  determining  the  total  acidity  before  and 
after  the  addition  of  the  carbonate  (Leo's  test). 

Significance  of  hydrochloric  acid.  In  the  acute  stages  of  fever.s, 
hydrochloric  acid  is  temporarily  diminished.  In  dilatation  of  the- 
stomach,  atrophic  gastritifj,  amyloid  degeneration,  some  forms  of  nerv- 
ous dyspepsia,  ana?mias,  cachexias,  and  Addison's  disease  hydro- 
chloric acid  is  permanently  diminished.  It  is  generally  absent  in  can- 
cer, especially  if  accompanied  by  extensive  gastritis,  and  may  be  ab- 
sent in  chronic  gastric  catarrh  and  extensive  deffeneration. 

DIGESTION  PRODUCTS. 

To  determine  the  efficacy  of  the  digestive  function  we  may  ex- 
amine the  products  formed  in  the  stomach  during  the  conversion  of 
proteids  into  peptones.  When  the  albuminous  compounds  named 
proteids  are  submitted  to  the  digestive  action  of  pepsin,  trypsin,  ren 
nin  and  certain  other  enzymes,  intermediate  products  are  produced  in 
the  course  of  the  conversion,  which  finally  become  peptones.  These 
intermediates  are  termed  albumoses  or  proteoses  and  the  process  is 
named  proteolysis.  When  pepsin  in  tJie  presence  of  hydrochloric  acid 
is  the  proteolytic  agent  a  small  proportion  of  the  proteid  is  first  con- 
verted into  acid-albumin,  which  may  be  precipitated  by  neutralizing 
the  fluid  during -the  early  stages  of  digestion.  At  a  later  stage  it  dis- 
appears and  other  albumoses  appear  as  the  result     of     hydrolysis. 


EXAMES^ATION  OP  THE  STOMACH  CONTENTS  30S- 

Some  of  these  substances  shoiild  be  present  in  the  residue  of  the  test- 
meal  removed  at  the  end  of  an  hour,  others  do  not  appear  until  a 
much  longer  period.  Native  proteids,  albumin  and  globulin  are  pre- 
cipitated by  slightly  acidulating  and  boiling. 

Acid  albumin  is  precipitated  by  exactly  neutralizing  the  solu- 
tion. The  -^  NaOH  may  be  used  with  phenolphthalein  as  the  in- 
dicator. 

Primary  albumoses.  which  may  be  taken  to  represent  the  next 
step,  are  obtained  by  first  removing  the  native  proteids  and  acid 
albumin  as  above,  then  saturating  the  filtrate  ^vith  ^IgSO^. 

Secondarii  albumoses.  Filter  out  the  above  primary  albumoses 
and  saturate  the  filtrate  with  (NH^)^  SO^.  Filter  and  test  the  filtrate 
for  peptone.  Peptones  are  tested  for  by  the  biuret  reaction,  ■s'iz :  To 
the  above  filtrate  add  one  e.  e.  of  KOH  or  XaOH  and  two  drops  of 
CuSO^  solution,  a  rose  or  red  color  indicates  peptone. 

Little  peptone  is  found  in  the  stomach  at  any  time  as  the  result 
of  gastric  proteolysis.  "Whether  this  is  due  to  the  fact  that  the  pro- 
cess stops  short  of  its  formation,  as  is  held  by  Ewald  and  G-umlich, 
or  to  the  immediate  absorption  when  formed,  is  undecided.  Even 
froni  the  small  intestine  it  rapidly  disappears. 

Starch.  The  salivary  diastase  continues  the  conversion  of  starch 
into  dextrin  and  maltose  until  free  hydrochloric  acid  appears,  which 
after  an  ordinary  meal  may  be  delayed  forty  minutes  to  one  houx", 
when  the  conversion  should  be  complete.  The  process  is  called 
amylolysis.  At  the  end  of  this  time  iodine  should  give  no  blue  color. 
Erythrodextrin  gives  a  reddish- violet  color  with  aqueous  solution  of 
iodine.  The  blue  or  purple  reaction  indicates  faulty  or  deficient  dias- 
tase in  the  saliva  or  excessive  acidity  of  the  gastric  jiiice. 

Pepsin.  The  efficacy  of  the  pepsin  is  tested  by  noting  its  action 
on  discs  of  coagulated  albumin — the  white  of  boiled  eggs.  When 
hydi'ochloric  acid  is  present  pepsin  is  rarely  absent  from  the  gastric 
juice.  In  its  absence  pepsinogen  may  be  present  and  is  converted  into  ■ 
pepsin  by  the  hydrochloric  acid.  Two  tests  should  be  made ;  one  with 
5  e.  e.  of  the  filtered  fluid,  the  other  with  the  fluid  plus  two  drops  of 
hydrochloric  acid,  using  discs  of  equal  size  and  thickness,  cut  from 
the  egg.  The  test  tubes  are  kept  at  a  temperature  of  100  F.,  and  ex- 
amined occcasionaUy  to  ascertain  the  effects.  If  no  liquefaction  oc- 
curs, pepsin  is  absent.  If  liquefaction  occurs  only  in  the  tube  to  which; 
acid  has  been  added,  this  substance  is  needed  to  develop  the  ferment.. 


304  EXAMINATION"   OF  TIIK  STOMACH    CONTENTS 

I\'(iiiiiii.  (Jaivi'ully  iiriil  fiilize  ")  v.  c.  of  Liiisd'ic  lliiid  ;iii(l  ;ilso  5 
c.  e.  of  milk.  Mix:  if  rennin  is  |>ri'scnt  coMunlaticui  oriMirs  in  Ini  to 
fifteen  minutes. 

The  rapidity  with  which  stoinaehie  alworption  takes  place  is  as- 
certained by  noting  the  time  at  which  tlie  iodine  reaction  occurs  in 
the  saliva  after  administration  of  potassium  iodide.  A  capsule,  care- 
fully wiped,  containing  three  grains  of  Kl  is  administered  and  at  the 
end  of  five  minutes  and  each  succeeding  minute,  the  saliva  is  tested 
with  strips  of  bibulous  paper  which  have  been  previously  soaked  in 
starch  paste  and  dried.  The  papers  are  moistened  on  the  tongue,  then 
touched  with  a  drop  of  commercial  nitric  acid,  which  always  contains 
traces  of  nitrous  acid.  Iodine  is  liberated  and  a  blue  spot  is  produced. 
The  reaction  should  occur  in  ten  to  fifteen  minutes.  When  Ww  reac- 
tion is  delayed  twenty  minutes  or  more  absorption  is  aluioiiiiMlly  de- 
layed and  indicates  disease  of  the  mucosa. 

The  motor  function  of  the  stomach  is  convenienlly  drteiiiiiiu'd 
by  Ewald's  salol  test  or  by  Fleischer's  method. 

Gastric  peristalsis  pumps  the  portions  of  prepared  food  products 
which  are  not  directly  absorbed  from  the  stomach,  through  the 
pylorus.  The  stomach  peristalsis  begins  about  tifteon  iniiuites  after 
food  ingestion,  and  gradually  becomes  more  and  more  energetic  until 
the  end  of  stomach  digestion,  which  lasts  four  or  five  hours.  Dila- 
tation of  tlie  stomach,  weakening  or  degeneration  of  its  muscular 
coats  and  pyloric  stenosis  interfere  with  the  food  transfer,  and  the 
contents  are  retained  abnormally  long  in  the  stomach.  On  the  other 
hand  I  have  frequently  found  that  in  persons  suffering  from  intes- 
tinal indigestion  of  the  catarrhal  order,  with  the  production  of 
diarrhcea,  the  stomach  peristalsis  is  abnormally  active.  Flei.scher  ad- 
mini.sters  a  cap.sule  containing  about  two  grains  of  iodoform,  which 
is  not  decomposed  in  the  stomach  but  which  is  converted  into  iodide  of 
sodium  in  the  duodenum.  The  capsule  is  administered  with  the  test- 
breakfast  and  iodine  should  appear  in  the  saliva  in  from  55  to  100 
minutes. 

Both  the  motor  and  absorption  powers  are  determined  by  remov- 
ing the  residue  of  the  te.st-breakfast  after  the  lapse  of  stated  times, 
-and  noting  the  amount.  After  two  and  a  half  hours,  there  should  be 
no  residue. 

Klemperer  introduces  100  c.  c.  olive    oil    into    the    washed-out 


EXAMINATION  OF  THE  STOJIACH  CONTENTS  305 

stomach  and  removes  the  nnabsoi'bed  portion  after  two  hours,  to  de- 
termine the  amount. 

Ewald  administers  a  capsule  containing  ten  grains  of  salol,  which 
is  not  absorbed  in  the  stomach,  but  which  splits  into  phenol  and  sali- 
cylic acid  in  the  duodenum.  Salicylic  acid  should  appear  in  the  urine 
in  one  hour-  or  one  hour  and  a  quarter  after  administration.  A  drop 
of  urine  is  caught  on  a  piece  of  filter  paper.  On  touching  the  middle 
of  the  drop  with  a  drop  of  10  per  cent,  solution  of  ferric  chloride  a 
violet  rim  appears  around  the  spot. 

JIucus.  When  not  apparent  to  the  eye  in  the  vomit  or  in  the 
residue,  mucus  is  not  in  excess.  It  is  increased  in  all  catarrhal  and 
inflammatory  conditions  and  then  occurs  in  ropy,  stringy  masses.  In 
chronic  alcoholics  and  drug  habitues  it  reaches  excessive  proportions. 
Mucus  is  recognized  by  shaking  the  sediment  with  dilute  NaOH,  fil- 
tering and  precipitating  the  dissolved  mucus  by  the  addition  of  acetic 
acid. 

MACEOSOPIC  EXAMINATION  OF  THE  EESIDUE. 

The  quantity,  character,  amount,  color,  odor  and  proportion  of 
mucus  are  noted.  The  residue  removed  five  or  six  hours  after  an  ordi- 
nary meal  furnishes  us  more  information  u^pon  these  points  than  does 
the  test-meal.  Particles  of  "food  from  preceding  meals  may  be  found. 
In  eases  of  acute  summer  gastritis  it  is  not  rare  to  find  in  the  vomit 
remnants  of  food  ingested  twenty-four  to  forty-eight  hours  previously. 
Excess  of  proteids  indicates  deficient  acidity.  Excess  of  starch  indi- 
cates excess  of  acidity. 

Bile  and  blood  are  visible  to  the  eye  when  present  in  any  quan- 
tity. 

MICKOSCOPIC  EXAMINATION. 

Food  particles  may  be  identified,  blood  and  pus  cells,  bacteria, 
yeast-eells,  sarcinas,  bile  stains  and  sometimes  particles  of  new- 
gro^^'ths  may  be  recognized.  Staining  with  methyl-blue  best  demon- 
strates bacteria,  which  are  always  present  in  the  stomach  and  are  un- 
doubtedly necessary  to  the  digestive  function.  Only  when  in  excess 
or  when  specific  forms,  the  product  of  specific  disease,  are  present 
can  they  be  considered  pathologic.  The  Boas-Oppler  bacillus  is 
found  in  carcinoma,  and  its  absence  is  generally  said  to  indicate  the 
absence  of  the  growi:h.  although  Osier  lays  more  stress  upon  the  pres- 
■enee  of  lactic  acid,  which  the  bacillus  is  thought  by  its  discoverer  to 


:}0()  EXAMINATIiiN   i>F    I'lIK  STUMACII   CONTKNTS 

Ix-  llic  I'liicf  iiislriiiiu'iil  ill  iiriMliiriiiL;'.  tluiii  upon  llic  hiicillus  itself. 
Sarciiiii'  are  in  excess  in  pyloric  obstruction  and  dilatation.  Fermen- 
tation i.s  due  to  bacterial  activity  and  produces  the  well-known  train 
of  symptoms  named  dyspepsia. 


SECTION  XV. 

EXAMINATION  OF  THE  URINE. 

The  advauees  made  in  physiologic  chemistry,  eombiued  with  the 
advances  made  in  microscopic  technique,  have  enhanced  the  ability  to 
interpret  the  changes  and  variations  which  occur  in  the  urine  both 
with  the  physiologic  and  metabolic  processes  of  the  body,  as  well  as 
in  the  pathologic  digressions  to  which  it  is  subject,  to  a  degree  little 
short  of  certainty.  The  uninterrupted  constancy  of  the  secretion  and 
the  ease  with  which  it  may  at  any  time  be  obtained,  otfer  us  an  un- 
excelled index  of  the  metabolic  changes  going  on  within  the  economy,, 
for  it  may  be  said  that  no  pathologic  process  can  serioitsly  disturb  the 
normal  cell  metabolism  without  producing  a  change  of  some  charac- 
ter in  the  urine,  which  preeminently  represents  the  result  of  that 
process,  and  more  quickly  than  any  other  product  indicates  a  dis- 
turbance of  normal  function.  Hence  the  application  of  urinalysis  to 
the  recognition  of  disease. 

THE   URIXE. 

Quaiifify.  The  average  quantity  of  urine  for  healthy  individuals 
is  1500  c.c,  or  about  fifty  ounces,  for  the  twenty-four  hours.  In  order 
to  determine  the  per  diem  amount  the  patient  should  be  provided  with 
a  clean  receptacle  which  can  be  tightly  covered,  capable  of  holding 
the  entire  quantity.  He  must  be  instructed  to  pass  the  urine  directly 
into  the  container  and  to  void  it  before  each  visit  to  .stool.  A  half- 
gallon  bottle  is  a  convenient  receptacle.  The  quantity  is  diminished 
by  perspiration  and  exhalations  of  moisture  and  increased  acti\'ity 
of  the  bowels.  Cold  and  dampness  increase  it:  hence  it  is  somewhat 
greater  in  winter.  Great  muscular  activity,  imbibition  of  large  quan- 
tities of  liquids  and  over-eating  increase  the  amount;  while  fasting 
and  abstemiousness  diminish  it. 

The  amount  secreted  is  greatest  after  mid-day  and  least  during 
sleep.  The  urine  is  increased  in  disease — in  diabetes,  chronic  inter- 
stitial nephritis  and  amyloid  degeneration  of  the  kidney,  and  in  those 


3(18  i:.\AMINATION    OF   THE   THINE 

forms  of  uiiriliae  hyiJiTtropliy  whicli  are  accoiupanifil  l)y  iiuTcased 
intra  vascular  pressure.  Temporary  abundance  succeeds  attacks  of 
hysteria  and  other  forms  of  convulsions. 

The  urine  is  decreased  in  acute  Bright's  diseasi-.  paii'iicli.\iiiatous 
nephritis,  cirrhosis  of  the  liver,  all  acute  fevers  ami  inllaiiiniations 
and  in  active  and  passive  hypenpmia  of  the  kidney,  as  in  carlN- 
Brigrht's  disease.  The  urine  may  be  decidedly  lessened  or  cvin  sup- 
pressed in  very  acute  inflammations  of  the  kidneys,  by  obstruction  oi: 
the  ureters,  by  great  internal  in.iuries,  and  in  profound  shock  or  col- 
lapse, in  the  algid  stage  of  cholera  and  in  cases  of  pronounced  poison 
of  infective  di-sease.  Complete  suppression  can  not  long  exist  without 
being  followed  by  urtemia  and  death. 

Before  deciding  upon  the  clinical  significance  of  increase  or 
diminution  of  the  volume  of  urine  voided,  careful  inquii-y  covering 
the  above  points  referable  to  diet  and  habits  should  be  made. 

Composition  of  the  urine.  The  normal  urinary  constituents  are 
derived  from  the  waste  products  of  the  liquids  and  solids  ingested  and 
from  the  result  of  retrograde  tissue  metamorphosis.  The  ni-ine  is 
chiefl.v  a  solution  of  urea  and  certain  organic  and  inorganic  salts,  hold- 
ing in  suspension  epithelial  cells  and  mucus.  Their  relative  amounts 
are  given  in  the  following  table  taken  fi-om  Parke's  schedule: 

Amount  of  urinary  constituents  passed  in  twenty-four  hours. 
Coiislituputs.  Weight  66  kiloa. 

Grammes. 

AVater   1500.00 

Total  .solids   72.00 

Urea    38.18 

T^rie  acid    0.55 

llippuric  acid    0.40 

Creatinin    0.91 

Pigment  and  other  organic  matters 10.00 

Sulphuric  acid    2.01 

Phosphoric  acid    3.16 

■   Chlorine   T-8.00 

Ammonia    0.77 

Potassitun 2.50 

Sodium   11.09 

Calcium    0.26 

jMagnesium 0.21 


EXAMINATION   OF   THE  URINE  309 

Each  1,000  grains  of  urine  contain  about  33  grains  of  solids,  of 
which  amount  25  grains  are  organic  and  8  to  10  grains  inorganic. 

Changes  produced  by  standing.  On  standing  certain  changes  are 
brought  about  in  the  composition  of  the  urine.  The  rapidity  of  these 
changes  depends  on  the  temperature  (being  produced  much  quicker 
at  high  temperatures),  the  accessibility  of  micro-organisms  and  the 
composition  of  the  urine  as  voided,  highly-acid  urine  withstanding  the 
changes  longest.  When  normal  acid  urine  is  allowed  to  stand  in  a 
tall,  conical  glass,  there  appears  after  some  hours  a  floating  cloud 
which  settles  near  the  bottom,  composed  of  mucus  in  which  is  en- 
tangled a  few  bladder  epithelial  cells.  In  a'  cold  room  this  occurs 
within  two  hours.  It  is  named  the  nubecula.  The  next  substance  to 
be  deposited  is  the  reddish  or  yellowish  alkaline  urates,  sodium,  potas- 
sium and  ammonium,  and  in  cold  urine  the  urates  of  the  alkaline 
earths,  calcium  and  magnesium.  The  latter  are  held  in  solution  in 
warm  urine.  The  next  deposit  to  occur  is  uric  acid,  which  crystals 
are  dark-red  or  brown  in  color  and  which  in  part  replaces  the  urates. 
At  the  same  time  or  a  little  later  form  octahedral  or  envelope  crystals 
of  calcium  oxalate.  Still  later  normal  urine  deposits  a  sediment  com- 
posed of  phosphates  of  the  alkaline  earths — granular,  amorphous  cal- 
cium phosphate  and  triangular  prismatic  crystals  of  triple  phosphate 
(ammonio-magnesium  phosphate) — often  interspersed  with  dark  spicu- 
Jated  spherules  of  ammonium  urate  (Purdy).  Upon  standing  for  a 
few  days  all  urines  become  turbid,  owing  to  the  swarms  of  bacteria 
which  appear  in  the  solution.  Such  turbidity  cannot  be  removed  by 
simple  filtration,  but  may  be  cleared  by  repeated  shakings  with  pow- 
dered charcoal  and  refiltering. 

After  a  varying  time,  depending  on  the  factors  named,  the  urea, 
is  transformed  into  carbonate  of  ammonia  and  the  normal  acid  re- 
action is  changed  to  alkaline.  The  change  may  come  about  in  forty-  ' 
eight  houi's  or  not  until  after  the  lapse  of  several  days.  This  change  is 
spoken  of  as  ammoniacal  decomposition  and  is  due  to  the  activity  of 
certain  micro-fungi,  as  first  pointed  out  by  Wormley.  By  the  same 
process  amorphous  urates  are  transformed  into  ammonii;m  urate,  uric 
acid  is  transposed  into  triple  phosphate,  and  calcium  phosphate  is 
deposited. 

Acid  fermentation  with  the  production  of  acetic  and  lactic  acid 
is  due  to  the  action  of  contained  mucus.    Uric  acid  and  the  urates  are 


310  KXAMIXATION    OF   TIIK   TRIXE 

J>ivfi|)it!i1rtl    liy    tlir    |inii'i'ss    Mild    tlii'    iicidily    (liiiiiiiislii'd.       Il    is    iml 
foiiinioii. 

('(liar,  'riic  ii(inn,-il  mlor  cif  the  iirinc  is  cIcMr-MiiilicT  or  si  raw- 
color,  diif  t(i  tlir  iirc'sciicc  n\'  urdliiliii  or  urocliroiii  and  iiroxani  liiii. 
Abnormal  coloriiiL;-  is  due  to  lilood,  liilr,  iiiolaiiiii,  liaMiioLiiohin.  v('l;c- 
table  C'oloriiifrs  and  Ihosr  d;'ri\<'d  rroiii  inrdicinal  soiii-ccs.  1  iiiliiliiiit: 
l-AVg(?  quantities  of  water  I'ciidi'is  il  paler,  and  ahsl  ineiice  and  si  rony 
diet  by  coneiMitration  increase  the  color.  .Vs  a  rule  liolli  the  ili^plli 
of  color  and  the  acidity  increase  with  tlie  specilic  L;ra\ity  and  the 
increase  of  the  solid  constituents,  and  vice  versa. 

In  disea.se  the  urine  is  deficient  in  coloring  matter  when  jilnindaiit. 
as  in  diabetes,  hysteria,  interstitial  nephritis  and  amyloid  kidney. 
In  the  first  it  may  have  a  pale-fi'reen  cast  when  viewed  with  trans- 
mitted light.  Fevers  and  disea.ses  which  concentrate  the  secretion  in- 
crease both  relatively  and  absolutely  the  amount  of  coloring  sub- 
stances. The  presence  of  blood  and  ha'moglobin  products  produces  a 
red  or  brown  color.  Bile  pigment  gives  the  urine  a  dirty-greenish 
tint.  Diabetic  urine  may  also  show  a  faint-greenish  tinge,  ('ai'liolic 
acid  and  creosote  coloi'  the  fluid  dark-brown  or  black,  santonin  im- 
parts a  yellow  color. 

Ofhir.  The  odor  of  fresh  iii'ine  \aries  witli  tlic  degree  of  concen- 
tration; sweetish,  aromatic,  charaeterisi ie,  it  has  given  rise  to  the 
ad.jective  "urinous."  The  odor  is  due  to  acid  derivatives  of  the 
phenyl  group.  Stale  urine  is  ammoniaeal.  Putrid  urine  is  due  to 
the  decomposition  of  mucus  and  other  organic  substances.  Foods  and 
drugs  influence  the  odor.  Asparagus,  garlic,  cabbage,  impart  a  well- 
recognized  odor,  and  the  essential  and  aromatic  oils  and  turpentine 
give  character  to  the  odor  of  the  urine.  C.vstitis  gives  rise  to  ammo- 
niaeal urine  (Nothnagel  says  acid).  Pyuria  has  the  odor  of  pus  or 
of  decomposition.  The  odor  of  acetone  is  often  notieeahle  in  the 
urine  of  eclampsia  and  of  diabetes. 

ludclion.  The  reaction  of  fresh  normal  urine  is  acid,  due  to  acid 
sodium  phosphate.  The  acidity  increases  for  several  hours  after  be- 
ing voided,  due  to  the  so-called  acid  fermentation.  During  this  period 
a  whitish  deposit,  sometimes  pink  or  red,  of  acid  urate  of  sodium  or 
uric  acid  is  deposited,  which  disappears  on  warming.  The  acidity  is 
least  between  meals:  early  morning  urine  may  be  alkaline.  Alkalinity 
(iue  to  ammonia  (inflammatory  alkalinity)  causes  red  litmus  to  turn 
blue  when  moistened  therewith,  hut  to  resume  its  original  color  when 


r  "■■^■"■■^-■-/■.-^'*^"''"'^ 

FaleYelloMT. 

Z 

LiqJit  Yelloiv. 

3 
Yellow. 

4-. 

Reddish  Yelloi^^. 

5 

Yellowish  Red. 

6. 
Red. 

7. 
Broimish  Red. 

8. 

Reddish  Brown. 

9. 

BroHTilsh  Black. 

PLATE  XXIV. 
VOGEL'S  SCALE  OF  URINE  TINTS. 


EXAMINATION  OF   THE  URINE 


311 


dry.  The  urine  is  rendered  alkaline  by  the  administration  of  alkalies, 
as  soda  or  potash,  the  alkaline  carbonates  or  the  salts  of  the  vegetable 
acids,  hence  a  vegetable  diet  reduces  acidity.  Acidity  is  increased  by 
administration  of  acids,  by  a  meat-diet  and  by  concentration. 

Specific  Gravity.  The  normal  specific  gravity  of  urine  varies 
from  1018  to  1022,  the  average  may  be  placed  at  1020,  but  varies  with 
food  and  drink.  Meat-diet,  active  exercise,  copious  sweating  raise  it 
above  this  figure.     Fluids  imbibed  lower  it.     Those  forms  of  Bright 's 


Fig.  71 — Sqiiibb's  Urinometer. 


•disease  with  increased  urine  are  accompanied  by  diminished  specific 
gravity,  while  the  acute  variety  and  diseases  which  diminish  or  con- 
'centi-ate  the  secretion  raise  the  figures.  When  in  disease  the  volume 
'of  the  urine  remains  unchanged  and  the  specific  gravity  falls,  it  means 
faulty  elimination  and  its  import  is  unfavorable.  The  presence  of 
■sugar  raises  the  specific  gravity,  and  urine  of  a  specific  gravity  of  1028 
or  over  should  be  examined  therefor.  Squibb 's  urinometer  is  recom- 
mended for  office  use.  Corrections  for  temperature  in  taking  the  spe- 
cific gravity  are  sometimes  necessary  in  very  hot  or  cold  weather. 
The  rule  is  to  add  one  degree  of  specific  gravity  for  every  10°  F.  of 
the  urine  above  the  decree  at  which  your  urinometer  is  standardized 


:U2  EXAMINATION   OP  THE  URINE 

( Squibb 's  at  77°  F.)  and  to  subtract  oiu^  def.'i'ee  for  each  10*^  F.  be- 
low standard. 

Ill  using  the  instrument  the  luilb  ot  the  iirinnineter  shoui(_l  be 
first  completely  imniorsed  and  care  should  be  taken  that  it  does  not 
rest  in  contact  with  the  side  of  the  container. 

Transparency.  Fresh  health.y  urine  is  clear.  If  urine  is  turbid 
when  passed  it  is  pathologic.  Mucus  renders  it  cloudy.  This  cloudi- 
ness is  unaffected  by  heat,  mineral  acids  or  alkalies,  but  is  increa.sed 
by  the  addition  of  acetic  acid.  Precipitates  of  urates,  carbonates  and 
phosphates  render  it  cloudy,  l^rates  redissolve  on  the  application  of 
heat,  phosphates  disappear  on  the  addition  of  mineral  acids.  In 
fevers,  the  quantity  of  urine  is  occasionally  so  small  that  the  urates 
separate  out  before  the  urine  leaves  the  bladder.  This  is  not  infre- 
quently the  case-  in  pneumonias  and  in  capillaiy  bronchitis  of  chil- 
dren, owing  to  deficient  oxydation.  Increase  of  turbidity  on  the  ap- 
plication of  heat  is  due  to  organic  sub.stances,  albumin,  pus  or  blood,  or 
to  earthy  phosphates.  Inci-eased  turbidity  on  the  addition  of  mineral 
acids  is  due  to  organic  elements. 

The  amount  of  solids  in  the  urine  is  obtained  appi'o.xiniately  by 
multiplying  the  last  two  figures  of  the  specific  gravity  by  2.33.  Tlie 
product  equals  the  number  of  grams  per  1,000  c.  c.  of  urine.  This 
number  is  known  as  Hiiser's  coefficient.  By  multiplying  by  0.233  the 
percentage  of  total  solids  is  at  once  obtained.  For  children  the 
coefficient  is  too  high,  1.80  should  be  used. 

The  average  excretion  of  solids  in  health  for  adults  is  sixty  grams 
per  diem,  but  decreases  about  10  per  cent,  for  each  decade  after 
forty.  Decided  decrease  points  to  renal  insufficiency,  and  in  ne- 
phritis portends  ura?mia.  In  the  course  of  any  acute  disease,  the  elim- 
ination of  solids  should  vary  with  the  temperature,  since  high  temper- 
ature means  active  tissue  metamorphosis,  hence  in  these  conditions 
decrease  in  solids  means  faulty  elimination. 

Of  the  ui'inary  solids,  urea  con.stitutes  the  greatest  proportion, 
being  normally  from  twenty  to  forty  grams  in  the  1500  c.  c.  per  diem 
urine,  with  an  average  of  thirty-three  grams.  Urea  represents  the 
ultimate  oxydation  of  nitrogen  in  the  organism. 

Acute  sthenic  conditions,  mental  and  mu.scular  activity  and  nitro- 
genous foods  increase  the  output  of  urea.  Chronic  diseases,  asthenic 
diseases.  Bright 's  disease,  and  diseases  of  the  liver  retard  the  elimina- 
tion of  urea. 


EXAMINATION  OP   THE  URINE 


313- 


Detection  of  Urea.  Place  a  few  drops  of  the  urine  on  a  glass 
slide  and  add  lialf  as  many  drops  of  nitric  acid.  On  warming,  rhombic 
and  hexagonal  crystals  of  nitrate  of  urea  are  formed  and  recognized 
under  the  microscope.  Fluids  which  do  not  give  this  reaction  are  not 
urine, — a  noteworthy  point. 

Quantitative  determination  of  urea  requires  practice.  The  ure- 
ometer  of  Doremus  is  sufficiently  accurate.  The  reaction  is  due  to 
the  fact  that  when  a  solution  of  urea  is  brought  into  contact  with  a 
solution  of  sodium  hypobromite,  the  urea  undergoes  decomposition 


Fig.  72 — Doremus'  Ureometer  and  Pipette. 

with  the  freeing  of  all  its  nitrogen.  Thus:  CON.H^+SNaBrO^CO,-!- 
3NaBr+2H„0+N„. 

The  long  arm  of  the  tube  is  filled  to  the  bend  with  the  sodium 
hypobromite  solution  by  inverting,  and  the  instrument  righted. 
Then,  with  a  graduated  pipette  one  c.  c.  of  urine  is  introduced  and 
slowly  discharged  beneath  the  surface  of  the  solution.  The  nitrogen 
set  free  rises  and  the  displaced  mixture  flows  into  the  bulb.  After 
ten  minutes  the  reading  is  taken.  The  scale  reads  in  milligrams, 
which  indicates  the  amount  per  c.  c.  of  urine.  Normal  urine  gives 
.02  gm.  per  c.  e.  which  is  two  per  cent.  Another  form  of  scale  gives 
the  percentag'e  or  grains  per  fluid  ounce. 

The  hypobromite  solution  must  be  freshly  prepared  as  follows: 
Dissolve  100  grams  of  sodium  hydroxid  in  250  c.  c.  water.     For  use,. 


314 


EXAMINATION    OF  THE  URIXE 


take  1(1  V.  e.  of  this  solution  and  add  1  e.  e.  of  bi-oininc.   mix  and 
dilute  with  10  c.  c.  water.    This  amount  is  sufticient  for  one  test. 

Owinjr  to  the  danfrers.  the  instability  and  the  disairreeahle  proper- 
ties of  bromine,  I  prefer  the  method  of  Bartley.  A  straijrht  tube, 
closed  at  one  end,  graduated  so  as  to  srive  the  number  of  gi'ains  per 
Huid  ounce,  a  pipette  holdinsr  one  c.  e.  and  the  ordinary  urine  pipette 
are  required.  The  tube  is  tilled  to  the  fifth  division  with  a  twenty 
per  cent,  solution  of  KBr.  Chlorinated  soda  solution.  XaClO  (Labar- 
raque's),  to  the  fifteenth  or  twentieth  division   is  added.     A   small 


Fig.  7.1 — Urea  from  aqueous  solution. 

quantity  of  piu-e  water  is  now  fioated  upon  the  top  of  these  reajjents 
by  inclining  the  tube  and  adding  the  water  from  the  pipette.  One 
c  c.  of  urine  is  now  carefully  floated  upon  the  water  by  the  same 
method.  Tightly  closing  the  open  end  with  the  thumb  the  tube  is 
inverted  and  shaken.  After  effervescence  eea.ses  the  surface  reading 
of  the  fluid  is  noted.  Still  closed,  the  tube  is  plunged  into  a  pail  of 
water  and  the  thumb  removed.  The  imprisoned  liquid  falls  and  the 
tube  is  immersed  until  the  outer  and  inner  liquids  are  at  the  same 
level,  and  the  reading  again  noted.  The  difference  in  the  two  read- 
ings is  the  number  of  grains  of  urea  in  one  fluid  ounce  of  urine,  which, 
multiplied  by  the  number  of  ounces  passed  in  twenty-four  hours, 
gives  the  number  of  grains  per  day.  A  quantity  of  le.ss  than  350 
grains  per  day  should  be  regarded  as  pathologic. 


EXAMINATION   OF  THE  URINE  315 

Uric  acid  is  readily  recognized  by  the  microscope.  Its  various 
■crystals  are  shown  in  the  figure.  If  urine  be  kept  until  ammoniacal 
decomposition  occurs,  uric  acid  crystals  deposit.  In  general,  condi- 
tions which  increase  urea  increase  uric  acid. 

Dyspnoea  and  impeded  respiration  increase  it.  Bright 's  disease 
and  gout  diminish  its  excretion.  The  normal  amount  is  0.6  to  0.8 
gms.  per  day.  It  is  determined  by  filtering  a  known  quantity  of  urine 
and  adding  5  c.  e.  of  HCl  to  each  100  c.  e.  After  twenty-tour  hoars 
collect  the  precipitate  on  a  previously -weighed  filter  paper,  wash,  dry, 
weigh  and  deduct  the  weight  of  paper.  The  result  is  the  weight  of 
uric  acid  in  the  amount  of  urine  employed. 

Ethereal  sulphates  in  excess  in  the.  urine  indicate  putrefactive 
■changes  of  grave  order,  within  or  outside  the  digestive  tract,  and  the 
increase  is  proportional  to  the  severity  of  the  process. 

Phenol  potassium  sulphate  and  indican  are  representatives  of  this 
group.  Both  indoxyl-potassium  sulphate  and  indolyl-sulphuric  acid 
are  known  as  indican,  and  respond  to  the  same  tests.  Excess  of  this 
substance  indicates  putrefaction  of  albumin  with  absorption  of  indol. 
It  especially  points  to  obstruction  of  the  small  intestine.  In  purulent 
pleurisy  and  peritonitis  it  occurs  in  abundance.  It  is  increased  in 
wasting  diseases  and  starvation,  hence  is  found  in  phthisis  and  cancer, 
likewise  in  dysentery,  typhoid  fever  and  acute  brain  diseases.  In 
Tiealth  the  urine  contains  a  mere  trace  of  the  ethereal  sulphates. 

Detection.  Mix  equal  quantities  of  urine  and  strong  HCl  in  a 
test  tube,  add  drop  by  drop  a  freshly  made  saturated  solution  of 
chlorinated  lime  (bleaching  powder)  or  chlorine  water,  until  the  solu- 
tion fails  to  darken  on  further  addition.  Shake  the  blue  solution 
with  chloroform  which  takes  up  the  indican  and  indicates  by  the 
-depth  of  its  color,  the  amount  present. 

Inorganic  Constituents.  The  chlorides  are  the  principal  inor- 
ganic constituent  of  the  urine  and  the  quantity  excreted  averages 
10  to  15  grams  daily,  thus  ranking  next  to  urea.  The  excretion  of  the 
chlorides  is  lessened  in  all  acute  febrile  diseases,  in  dropsies  and  serous 
exudations.  In  grave  cases  of  pneumonia  they  may  disappear  from 
the  urine.  In  rheumatism  their  sudden  disappearance  should  arouse 
the  suspicion  of  endocarditis  or  pericarditis.  Their  reappearance  or 
increase  is  favorable  from  a  prognostic  point  in  all  these  conditions. 

The  chlorides  are  precipitated  by  solutions  of  nitrate  of  silver. 


316  EXAMINATION    (IK   THE   IKINE 

lu  most  cases  au  approximate  estimate  dl:  their  iiuaiilily  is  all  llial 
is  necessary  to  tlie  clinician.    I  have  used  the  following: 

Add  to  a  volume  of  urine  a  few  drops  of  nitric  acid,  then  a  solu- 
tion of  AgXOj  (1  to  20).  The  chloride  of  silver  falls  as  a  white,  eiirdy 
precipitate  which  should  occupy  one-fourth  of  the  volume  of  the 
urine  taken.  If  the  precipitate,  after  standing,  occupies  much  more 
or  less  than  this  volume  the  chlorides  are  increased  or  diminislied.  A 
counter-test  with  normal  urine  always  should  be  made  for  comparison. 
The  silver  nitrate  solution  should  lie  added,  drop  by  drop,  until  its 
fu)-ther  addition  fails  to  produce  a  precipitate. 

Ultzmaun's  method:  A  standard  sohitiou  of  nitrate  of  silver, 
one  drachm  to  the  ounce,  is  prepared.  To  half-a-glass  of  urine  add  a 
few  drops  of  nitric  acid,  then  one  or  two  drops  of  the  silver  solution. 
"If  a  white,  flaky  precipitate  occurs,  (piiekly  sinking  to  the  bottom 
without  diffusing,  the  chlorides  are  undiminished.  If  simple  cloud- 
iness, without  curdy  flakes,  appears  and  readily  dift'u.ses,  the  chlorides 
are  diminished  to  0.1  per  cent,  (normal,  0.5  to  1.0  per  cent.).  Should 
no  precipitate  occur  the  chlorides  are  absent." 

F'Jiospltatcs.  The  amount  of  phosphoric  acid  in  the  da>'s  urine 
varies  between  2.5  and  3.5  grams,  excreted  as  alkaline  aiul  earthy 
phosphates. 

The  earthy-  phosphates  are  insoluble  in  alkaline  iiiiin'  and  on 
heating  the  precipitate  is  increased  and  may  be  mistaken  for  albumin. 
They  disappear  on  the  addition  of  acid,  while  albumin  remains. 
Triple  phosphates  are  not  present  in  normal  urine  when  voided,  but 
form  on  standing.  In  eystitic  urine  they  are  found..  The  acidity  of 
the  urine  depends  upon  the  presence  of  acid  sodium  phosphate.  Acute 
fevers,  gout,  most  kidney  diseases  and  pregnancy  diminish  the  phos- 
phates. Wastings,  especially  osteo-malacia  and  rickets  increase  their 
excretion. 

The  earthy  phosphates  are  precipitated  by  rendering  Uv  urine 
alkaline  and  heating. 

The  alkaline  phosphates  are  precipitated  by  magnesium  mixture, 
which  is  composed  of  MgSO^  and  NH^Cl,  each  one  part :  aq.  ammonia, 
one  part ;  water,  eight  parts. 

The  sulphates  in  the  urine  increase  or  diminish  in  general  with 
the  urea. 


PLATE    XXV. 


Triple  phosphate;  ammonium  urate;  bacteria. 
Alkaline  fermentation. 


EXAMINATION   OF   THE  URINE  317 

ABNORMAL  CONSTITUENTS  OF  THE  UEINE. 

Albumin.  Of  all  the  abnormal  constituents  of  the  urine,  from  a 
clinical  standpoint,  the  greatest  interest  centers  upon  albumin  and 
its  significance.  Briefly  summarized,  its  presence  means  alteration  in 
the  structure  of  the  kidney,  alteration  in  the  composition  of  the  blood 
or  of  blood  pressure. 

1.  Albuminurw  witliout  coarse  renal  lesions  is  a  matter  of  dis- 
pute. After  cold-bathing,  muscular  exercise,  dyspepsia,  hj^steria  and 
violent  emotions,  it  is  found  in  the  urine  occasionally,  and  the  changes 
which  permit  the  transudate  are  certainly  not  permanent.  Cyclic  or 
adolescent  albuminviria  is  interesting.  Boys  are  oftenest  the  subjects 
and  recovery  follows  after  a  varying  period. 

After  sixty,  it  is  not  uncommon  to  encounter  small  quantities  of 
albumin  in  the  urine,  associated  with  mucin,  and  the  tendency  in- 
creases with  each  decade  thereafter. 

2.  Alhtminuria  of  pyrexia.  Albumin  may  be  present  in  fevei-s 
of  almost  any  degree,  the  lesions  which  cause  it  generally  passing 
away  with  the  disappearance  of  the  primary  disease.  It  is  seen  in 
tonsillitis,  typhoid  fever,  pneumonia,  malaria,  the  entire  group  of 
specific  infections  diseases  which  used  to  be  called  zymotic,  cholera, 
yellow  fever  and  other  infections. 

3.  Albuminuria  clue  to  blood  cliangcs.  All  profound  ana?mias, 
leukfemia,  purpura,  syphilis,  scurvy,  rickets,  poisoning  by  metallic 
substances  as  arsenic,  lead,  mercurj'  or  phosphorus,  are  followed  by 
albuminuria  which  in  some  cases  is  transient,  in  others  leads  to  per- 
manent lesions.  The  administration  of  anaesthetics  is  followed  in  rare 
cases  by  albumin.  Certain  states  and  conditions  also  manifest  tran- 
sient albuminuria,  as  the  puerperal  state,  exophthalmic  goitre,  tetanic 
seizures,  after  apoplexy  and  epileptic  fits,  purpura  and  hospital 
gangrene. 

4.  Albuminuria  with  kidney  lesions.  Here  the  transudate  oc- 
curs in  states  of  active  congestion,  as  in  inflammations  of  the  kidneys ; 
in  passive  congestion  due  to  obstruction  or  pressure,  or  such  as  occurs 
in  organic  heart  and  lung  diseases.  Organic  lesions  of  the  kidneys, 
constituting  the  entire  group  of  Bright 's  diseases,  the  degenerations 
and  suppurative  processes  of  the  organs  and  growths  within  their 
structure,  constitute  the  chief  causes  of  albuminuria. 

5.  Pus-produciny  inflammations  of  any  part  of  the  urinary  tract 
are  accompanied  by  albumin  in  the  urine. 


318  EXAMINATION    HI'   THE   LHINE 

().  AlOiiniiiiuria  accoiiipanijiiif/  iinix  ilinu  tils  tn  tin  <ini(hiliiiii, 
ill  whiuli  the  kidneys  are  uot  priniarily  involved,  as  tumors.  al)doiniiial 
irrowths,  cirrhosis  and  other  changes  in  the  liver. 

The  amount  of  albumin  cannot  be  taken  ;is  iiidirjitivi'  of  the 
jrravity  <>1'  the  lesion,  since  in  some  serious  altfratimis.  such  as  inter- 
stitial nephritis,  the  amount  is  small  and  intermittent:  nor  can  albu- 
nun  without  other  evidences  of  i-enal  alteration  be  accepted  as  indica- 
tive of  organic  disease,  but  in  Ljviicral.  its  inci'cast'  i>r  (icd'ease  in  estab- 
lished recognized  conditions,  iiulirates  the  i;ra\ity  of  the  causative 
disease. 

I'esfs  for  Albuiniii.  'ryi)ical  albuuiinous  uiiiif  is  of  low  specilic, 
gravity,  pale  greenish-yellow  in  <'olor.  ami  forms  a  inrinanrnt  froth 
when  shaken.  Soon  after  being  passed  a  sediment  is  dcpositetl. 

The  potassium  ferro-cyanide  test  is  one  of  the  easiest  and  most 
reliable  tests  at  command.  I  have  found  it  most  satisfactory.  It  may 
be  applied  as  follows:  A  quantity  of  urine  is  placed  in  a  test  tube, 
half  as  much  of  a  solution  of  pota.ssium  ferro-cyanide  of  a  strength 
of  1  to  10  is  added  and  the  tube  shaken.  On  the  addition  of  a  few 
drops  of  acetic  acid,  albumin,  if  present  in  any  form,  is  i)r(>fi])itated 
in  a  fiocculent  cloud.  'I'ho  test  gives  no  ro;u'1ioii  willi  inucin  if  th<' 
acetic  acid  be  added  hisl.  and  no  reaction  with  phospluitcs  oi'  ui'ates, 
hence  any  precipitate  which  occurs  is  albumin.  ali)umose  or  nucleo- 
albumin. 

.\nother  method  of  aiiplyiuu  tln'  lost  is  to  add  acetic  arid  lirst 
and  filter  out  the  precipitated  mucin,  then  float  the  clear  acidified 
urine  upon  the  top  of  the  ferro-cyanide  .solution.  A  white  zone  form- 
ing at  the  point  of  contact  indicates  albumin. 

Heller's  test.  This  test  is  probably  more  univei'sally  umhI  than 
any  other  test  and  is  reliable  to  those  familiar  with  its  vai-iations.  A 
test  tube  is  filled  to  the  depth  of  one  inch  with  pure  nitric  acid.  A 
long  pipette  is  filled  with  urine,  which  is  floated  upon  the  sui'face  of 
the  acid  by  considerably  inclining  the  tube  and  slowly  discharging  the. 
urine  against  its  side.  The  presence  of  albumin  of  any  kind  is  indi- 
cated by  a  white  zone  at  the  point  of  contact.  The  width  varies  with 
the  amotuit  of  albumin  present. 

The  amorphous  urates  when  precipitated  by  fliis  metliod  appear 
as  a  brown  cloud  or  zone  in  the  urine,  above,  and  not  <il  Ww  point  of 
contact,  and  can  hardly  be  mistaken  for  albumin.  'I'lieii-  density 
dimini.shes  upwards.     ]\lncin  may  .show  as  a  cloud  towards  the  top  of 


EXAMINATION   OF   THE  URINE  319 

the  tube.  The  only  probable  erroi-  is  in  patients  who  have  been 
taking  balsams,  in  which  case  the  precipitate  resembles  aUnimin,  but 
is  cleared  by  addition  of  a  small  quantity  of  alcohol.  While  the  pre- 
cipitate generally  appears  immediately,  yet  when  very  scanty  may 
require  a  few  minutes  to  form,  hence  the  tube  should  be  re-examined 
at  the  end  of  half  an  hour. 

Boiling  the  urine  in  a  tube  coagulates  albumin,  and  also  pre- 
cipitates the  earth  phosphates.  The  latter  redissolve  on  the  addition 
of  nitric  acid,  which  should  be  added  drop-by-drop  as  the  urine  is 
reboiled.  Albumin  in  small  quantity  is  apt  to  escape  detection  by 
this  test  and  excess  of  phosphates  may  deceive  the  observer.  The  test 
is  reliable  for  albumin  in  considerable  quantity,  but  is  inferior  to 
either  of  the  other  tests  given  and  less  easy  of  manipulation. 

Mucin.  Mucin  is  the  secretion  of  the  mucous  cells.  It  is  a 
gluco-proteid,  i.  e.  a  compound  of  a  proteid  and  a  carbo-hydrate  and 
is  closely  related  to  the  albumins,  hence  constitutes  a  fruitful  source 
of  error  in  searching  for  small  quantities  of  albumin,  especially  if  the 
amount  of  mucin  is  increased.  It  is  present  in  all  urine  and  in  inflam- 
matory conditions  of  the  urinary  tract  is  increased.  In  catarrhal 
inflammations  of  the  pelvis,  of  the  kidney  or  the  bladder  the  amount 
may  be  enormous.  Mucin  is  increased  in  febrile  processes  and  is 
sometimes  the  forerunner  of  albumin  in  these  eases. 

It  is  not  coagulable  by  heat  and  is  soluble  in  strong  mineral  acids 
and  in  alkalies,  but  is  precipitated  by  acetic  acid,  alum  and  very 
dilute  mineral  acids,  which  latter  property  gives  rise  to  the  propensity 
to  mistake  it  for  albumin.  Mucin  is  insoluble  in  alcohol,  ether,  or 
chloroform.  Owing  to  its  solutions  dissolving  oxide  of  copper,  the 
presence  of  mucin  in  abundance  hinders  the  test  for  sugar. 

Detection :  Dilute  the  urine  to  double  its  volume  and  add  excess 
of  acetic  acid.    The  mucin  is  precipitated. 

Pus.  Pus  renders  the  urine  turbid  to  the  naked  eye.  It  quickly 
deposits  as  a  whitish  or  greenish  sediment.  The  supernatant  liquid 
contains  albumin  and  globulin.  Heat  does  not  dissipate  the  sediment, 
hence  distinguishes  it  from  urates.  Acids  do  not  dissolve  it  as  they 
do  the  earthy  phosphates.  The  addition  of  strong  alkaline  solutions 
dissolves  it  with  the  production  of  viscid  or  ropy  masses  (Donne's 
test).  The  addition  of  hydrogen  dioxide  causes  rapid  efliervescence, — 
a  valuable  test  for  pus  in  any  fluid. 

The  microscope  shows  characteristic  cells. 


320 


EXAMINATION   OK  THE   URINE 


CARBOHYDRATES. 

While  glucose,  levulose,  iuosite  and  lactose  may  occur  in  the  urine, 
the  most  important  clinically  is  glucose.  Whether  or  not  glucose  is  a 
■constituent  of  normal  urine  is  still  disputed.  Very  delicate  tests  fre- 
quently demonstrate  it  in  urine  otherwise  normal.  When  glucose 
appears  in  the  urine  in  appreciable  amount  it  is  known  as  glycosuria. 

Glycosuria  may  appear  as  a  temporary  condition  in  various  dis- 
-eases  of  the  brain  and  cord,  lungs,  liver,  heart,  during  pregnancy  and 


Fig.  74 — Lipogenic  Glycosuria.     Urine  also  contains  albumin. 

in  certain  infectious  diseases,  as  diphtheria,  influenza,  rheumatism, 
typhoid  fever,  syphilis,  scarlet  fever,  cholera  and  cerebro-spinal 
meningitis. 

It  is  often  encountered  in  obese  persons,  particularly  Hebrews, 
and  is  Imown  as  lipogenic  glycosuria.  Certain  drugs  and  toxic  mate- 
rials produce  a  substance  which  gives  to  the  urine  a  similar  i-eaction, 
as  morphia,  chloral,  hydrocyanic  acid  and  amyl  nitrite.  Both  tem- 
porary and  permanent  glycosuria  have  followed  the  inhalation  of 
nitrous  oxide.  The  internal  use  of  turpentine,  of  salicylic  acid,  mer- 
cury, alcohol  and  a  few  other  substances  is  sometimes  followed  by 
the  reaction.  Phloridzin,  and  some  of  the  .other  substances  mentioned, 
produce  glycosuria  by  directly  attacking  the  renal  epithelium  and 
destroying  its  power  to  keep  back  glucose.    The  ingestion  of  a  larger 


EXAMINATION   OF  THE  URINT;  321 

quantity  of  earbo-hydi-ates  and  peptones  than  the  liver  can  take  care 
of,  .causes  a  temporary  glycosuria. 

Persistent  gh'cosuria  is  knowTi  as  diabetes.  It  is  not  a  disease 
but  a  symptom  and  the  causative  lesion  must  be  looked  for  in  the 
liver :  the  pancreas — which  shows  lesions  in  fifty  per  cent :  the  nervoiis 
system — where  several  lesions  have  been  found  in  connection  with 
cases,  but  none  tj-pical;  or  in  the  kidneys.  The  heart,  the  lungs  and 
other  organs  show  frequent  lesions  which  are  all  probably  secondary. 

Diabetic  ui-ine  is  generally  pale  straw-color,  often  with  a  greenish 
tint,  has  a  characteristic,  sweetish  odor  and  taste,  and  a  specific 
gravity  varying  between  1030  and  1050.  The  amount  of  sugar  present 
varies  from  two  to  twelve  per  cent.  The  quantitv'  of  urine  is  much 
increased,  being  seldom  less  than  1600  c.  c.  and  may  reach  8000  c.  c. 
per  diem.  The  gra\'ity  of  the  disease  increases  with  the  pohiiria. 
Glycosuria  without  polyuria  is  seldom  fatal,  especially  in  advanced 
life.  The  severity  of  the  disease  in  aU  cases  bears  a  relationship  to 
age.  In  the  young  it  is  progressive  and  almost  uniformly  fatal,  riui- 
ning  its  course  in  a  few  months  to  a  few  years.  After  thirty-five  the 
disease  progresses  slowly  and  the  prognosis  is  better.  After  fifty,  it  is 
often  amenable  to  treatment. 

Tests  for  glucose.  The  methods  of  detection  most  often  used  are 
by  means  of  the  copper  tests,  which  depend  upon  the  fact  that  solu- 
tions of  grape  sugar  in  the  presence  of  an  alkali  reduce  euprie  oxide 
to  lower  oxides.  The  presence  of  albumin  interferes  more  or  less  with 
the  tests  and,  as  it  is  easily  removed  by  boiling  and  filtering,  it  is 
wise  to  do  so. 

Trommer's  test.  Add  to  a  quantity  of  urine  in  a  test  tube  about 
half  its  volume  of  sodium  or  potassium  hydroxide.  Then  add,  drop 
by  drop,  a  solution  of  copper  sulphate  (1  to  8)  until  a  slight  bluish- 
white  precipitate  is  formed.  The  precipitate  is  cupric  hydroxide. 
In  the  presence  of  glucose  it  is  dissolved  on  shaking  and  a  dark-blue 
color  results.  On  heating,  if  glucose  be  p^-esent.  red  cuprous  oxide  and 
yellow  cuprous  hydroxide  fall,  just  as  the  boiling  point  is  reached. 
If,  instead  of  boiling,  the  tube  is  allowed  to  stand  for  half  an  hour  the 
same  reduction  occurs.  With  heat  the  test  is  extremely  delicate.  If 
no  precipitate  occurs,  sugar  is  absent. 

Precautions.  If  sugar  is  present  in  considerable  quantity,  the  pre- 
cipitate forms  without  boiling.  The  urine  should  not  be  kept  boiling, 
iut  merely  hrougM  to  the  foiling  point,  since  continued  boiling  causes 


'■V22  KXA.MINATION    DF   THE   LKINK 

otlu'i-  substances  to  rediK-i-  llu-  copiicr,  .is  uric  acid,  crcatiu.  mucus, 
albniniii.  iieptones.  hypoxauthiu.  crcatiniu,  udycuroiiic  acid,  carbolic 
acid,  certain  alkaloids  and  excess  of  colorinji  matter.  As  a  rule,  these 
give  a  greenish  or  greenish-yellow,  not  n  red.  deposit. 

Precipitate  of  phosphates  may  occur  on  the  addition  of  the 
hydroxide,  but  is  white  and  tloccnliiii  ami  licars  no  resemblance  to  the 
red,  granular  cuprous  oxide.  A  yellow  precipitate,  which  falls  on 
cooling,  is  cuprous  oxide  and  is  not  due  to  glucose  .\  red  grainlar 
precipitate  is  very  probably  sugar. 

Ilainc's  test.  This  is  a  modification  of  Fehling's  test.  Foruuila: 
Pure  copper  sulphate,  30  grains:  distilled  water,  V2  ounce,  dissolve; 
add  pure  glycerine,  i/o  ounce:  mix  and  add  :">  oiuices  liquor  pota.ssie. 
Tlie  solution  is  somewhat  more  stable  than  Fehling"s  solutiim. 

Method:  Boil  one  drachm  of  the  test  Huid  in  a  lul)c  and  note 
whether  it  remains  clear.  Add  six  to  eight  drops  of  urine  and  rci)oil. 
A  copious  red  or  yellow  precipitate  indicates  .sugar.  If  no  precipitate 
occurs,  sugar  is  absent.  Here  again  the  alkali  may  precipitate  the 
earthy  phosphates,  but  they  should  not  be  mistaken  for  sugar.  The 
precautions  given  luider  Trommer's  test  shoidd  be  observed. 

Fehling's  test  is  applied  in  the  same  manner  as  Haine"s.  The 
(|nantity  of  urine  added  should  never  exceed  the  volume  of  the  test 
sill  111  ion  used.    l'\^hling's  solution  is.  best  prepared  in  two  parts. 

1. — Dissolve  34.64  gi'ams  of  crystallized  ("uSO,  in  watci-  ana 
dilute  to  500  c.  c. 

II. — 173  grams  Rochelle  salt  and  (iO  grams  \aOII  ai'c  dissolved 
in  water  and  diluted  to  500  e.  c. 

For  Tise,  mix  equal  volumes.  This  solution  is  also  used  for  quanti- 
tative examination,  10  c.  c.  of  the  mixed  solution  equals  0.05  grams 
glucose. 

Phcnylhydrazin  Its/.  AVhen  this  substance  is  boiled  with  grape 
sugar  a  characteristic  crystalline  compound  results. 

Te.st :  To  50  c.  c.  of  suspected  urine  add  2  gms.  phenylhydra/.in 
hydrochloride,  and  2  gms.  sodium  acetate,  10  c.  c.  of  water  may  be 
added  to  promote  solution.  Dissolve,  and  heat  on  water-bath  for  one 
hour.  On  cooling,  a  yellow  deposit  forms,  a  few  drops  of  which  is 
placed  on  a  glass  slide.  Bright,  needle-like  cry.stals  of  phenyl trlucosa- 
zone  are  formed,  rarely  invisible  to  the  naked  eye.  Scales  and  brown 
granules  are  not  indications  of  sugar.  The  microscope  shows  radiat- 
insr  aeicular  structure.    The  ervstals  indicate  that  the  ui'ine  contained 


EXAMINATION   OP   THE   URINE  323 

a  carbo-hydrate  aud  the  test  is  therefore  reliable.  None  of  the  sub- 
stances mentioned  under  Trommer's  test  is  capable  of  producing  the 
reaction. 

Quantitative  Determinution  of  Sugar.  The  amount  of  sugar  in. 
tlie  urine  indicates  the  severity  of  the  disease  and  is  the  basis  of  prog- 
nosis. Its  increase  or  diminution  is  the  best  evidence  of  the  result  of 
treatment. 

Roberts'  differential  test  is  accurate  and  simple,  but  requires 
twenty-four  hours  for  its  determination. 

Method:  Place  -t  ounces  urine  in  a  large  bottle,  add  1,4  cake  of 
compressed  yeast  and  cork  with  a  perforated  cork.  The  same  quan- 
.tity  of  urine  is  placed  in  another  bottle  and  corked.  Both  are  allowed 
to  stand  twenty-four  hours.  The  alcohol  and  carbonic  anhydride 
formed  by  the  fermentation  reduce  the  specific  gravity  one  degree  for 
each  grain  of  sugar  per  fl.  oz.  of  urine.  Thus,  if  the  sp.  gr.  is  reduced 
from  1040  to  1030,  the  urine  contains  ten  grains  of  sugar  per  ounce. 

When  fermentation  is  completed  the  urines  are,  decanted  and  the 
sp.  gr.  of  each  separately  obtained.  The  number  of  degrees  of  den- 
sity lost  in  the  fermented  urine  indicates  the  amount  of  sugar  per 
ounce,  or,  the  number  of  degrees  lost  multiplied  by  0.23  giv(5s  the 
percentage  of  glucose.    The  I'esults  are  approximately  accurate. 

Fehling's  test  is  the  mo.st  satisfactory  yet  devised.  The  only 
ob.jection  that  can  be  urged  is  that  practice  is  necessary  to  detei-mine' 
the  precise  point  of  reduction. 

Method:  10  e.  c.  of  Fehling's  solution  and  30  c.  c.  water  are 
measured  into  a  porcelain  dish  and  kept  at  the  boiling  point  over  a 
Bunsen  burner  or  alcohol  lamp.  The  urine  is  added,  drop  by  drop, 
from  a  burette  until  the  blue  color  of  the  Fehling's  solution  has  en- 
tirely disappeared.  The  number  of  e.  c.  of  urine  required  to  prodiice 
this  result  is  noted  and  the  sugar  calculated  thus :  It  requires  0.05 
gm.  of  sugar  to  remove  the  coloration  of  the  ten  c.  c.  of  solution  used, 
hence  the  number  of  c.  c.  of  urine  dropped  contained  0.05  gm.  of 
sugar.  Say  2  c.  c.  of  urine  were  used,  then  100  c.  c.  which  is  50X2 
contained  50x0.05  or  2.5  grams  per  100  c.  c.  By  dividing  5  by  the, 
number  of  c.  c.  of  urine  used  the  result  is  the  same,  and  the  per  cent, 
thus  easily  obtained. 

When  considerable  sugar  is  present  the  urine  should  be  diluted 
with  a  known  volume  of  water,  as  one  to  five,  and  the  result  corrected 
in  accordance  with  the  dilution. 


324  i:x.\  Ml  NATION-    Oi'  THE   LlilNK 

Accluinnia.  WIu'IIht  acclniic  oi-cius  in  lu':illli\-  urine  or  mil  is 
disputed.  It  oeciirs  after  alcoliulie  iiidulgeuee,  over-eatinj;  oi'  |)roteids 
and  in  the  urine  of  ehildreu.  It  oeeurs  in  fevers  and  rises  and  falls 
with  the  temperature  curve.  It  is  often  associated  with  eareiuoma 
and  should  be  sought  for  in  suspected  cases.  In  diabetes  its  appear- 
ance often  precedes  diaceturia.  It  is  capable  of  produciui;  a  species 
of  auto-intoxieation,  and  often  occurs  in  the  insanities. 

ClKiKtard's  test  is  the  simplest.  An  aqueous  solution  of  ma.sreiila 
is  decolorized  with  sulphurous  acid.  A  drop  of  this  solution  addetl  to 
fluids  eoutainiu";'  acetone  gives  a  violet  color.  When  the  aiuoiint  oi' 
acetone  is  very  minute,  the  color  develops  after  five  minutes. 

Diaceturia.  Ethyl-diacetic  acid  in  the  ui'ine  is  of  serious  im- 
port. It  occurs  under  the  same  febrile  conditions  as  acietone.  in 
diabetes  it  is  the  premonitor  of  c(nii:i  ;md  signifies  death.  It  occurs 
ofteuest  in  young  subjects.  .Vi-c-oiding  to  von  Jaksch.  the  cause  of 
coma  in  diabetes  is  diaeetic  acid. 

Detection:  Boil  a  sample  of  the  mine  and  add  a  few  drops  of 
ferric  chloride.  A  deep-red  color  is  produced.  If  the  phosphates  are 
precipitated,  add  the  chloi'ide  luitil  itrecipitation  ceases,  filter  and  re- 
peat the  test.  Xo  oilier  substance  ui\-es  I'ise  to  flie  red  color  in  the 
boiled  urine. 

;  BILE. 

Bile  acids  and  bile  salts  apjieiir  in  the  urine  (lui-iuL;  atlarks  of 
jaundice.  Increase  of  bile  salts  occurs  with  the  termination  of  "bilious 
•attacks."  They  are  increased  in  many  forms  of  organic  dis- 
'ease  of  the  liver,  in  .splenic  leucocythiemia  and  an:emia.  Bile  pig- 
ments are  found  in  the  urine  in  phosphorous  poisoning,  in  grave  dis- 
orders of  the  liver,  in  obstructive  jaundice,  where  the  coloring  matter 
reaches  the  urine  through  the  circulation,  and  precedes  its  appear- 
ance on  the  skin.  Both  may  appear  during  excessive  summer  heat 
and  after  the  use  of  alcohol.  The  color  of  the  urine  is  yellow,  green, 
brown  or  black.  On  shaking  it  yields  a  yellow  froth  whicl;  is  charac- 
teristic and  in  the  absence  of  ingested  drugs  such  as  rhubarb,  chrys- 
orobin  and  the  like,  is  distinctive. 

Gmeli)i.'s  test  for  Bile  Figment.  A  small  (|n,-inti1y'of  eonnnei'cial 
nitric  acid  (yellow  nitrous  acid)  is  placed  in  a  test  tube  and  the  urine 
is  floated  upon  it.  A  rainbow  coloration  appears  at  the  point  of  con- 
tact.   Or  the  u.rine  may  be  pass.'d  fhi'ouiih  filter  jiaper.  and  a  drop  of 


EXAHIXATIOX   OF  THE  URIXE  OJlO 

the  acid  placed  iu  the  center  of  the  wet  paper,  when  the  colored  rings 
appear. 

THE  DIAZO-REACTIOX  OF  EHRLICH. 

This  test  was  proposed  by  Ehrlieh  in  18S2  as  a  valuable  diagnos- 
tic sign  of  typhoid  fever.  Although  the  reaction  occiu's  in  a  few  other 
diseases,  as  pulmonary  tuberculosis,  yet  in  the  cases  most  often  mis- 
taken for  typhoid  fever  the  reaction  does  not  occur,  viz.,  malaria.  I 
studied  the  urine  in  36  cases  of  t>T)hoid  fever  in  soldiers  retui-ned 
from  Tampa.  The  reaction  was  pronounced  iu  3.5.  It  was  absent  in 
all  cases  of  malaria  when  typhoid  was  absent. 

It  occurs  from  the  fourth  to  the  seventh  day  and  thereafter.  The 
intensity  of  the  reaction  varies  with  the  gravity  of  the  case.  When 
absent,- the  diagnosis  is  doubtful.  It  occurs  in  rapidly  fatal  eases  of 
phthisis,  sometimes  in  measles,  miliary  tuberculosis,  pyasmia,  scarlet 
fever  and  erysipelas.  It  is  absent  in  apyrexial  disease  (Ehrlieh).  Two 
solutions  are  prepared: 

I. — 2  grams  of  sulphanilic  acid :  50  c.  c.  HCl :  1.000  c.  c.  water. 
Mix. 

II. — A  0.5  per  cent,  solution  of  sodium  nitrite. 

[Method :  50  parts  of  Xo.  I  and  one  part  of  Xo.  II  are  placed  in 
a  test  tube,  an  equal  quantity  of  urine  added,  and  the  solutions  well 
mixed.  About  %  of  the  voliune  of  ammonia  is  then  added.  If  the 
reaction  is  positive  a  carmine  or  cherry-red  color  develops,  and  on 
shaking  the  color  extends  to  the  foam.  Von  Jaksch  thinks  the  re- 
action due  to  acetone  andnot  especially  significant  of  typhoid. 

URIXARY  SEDIJIEXT. 

Wheii  urine  is  allowed  to  stand  for  some  hours  gravitj'  causes  it 
to  separate  into  two  layers,  the  solid  portions  or  sediment  and  the 
supernatant  liquid.  The  solids  consist  of  insoluble  materials  contained 
in  the  fluid  and  soluble  substances  which  by  chemical  activity  or 
crj'stallization  have  been  separated  from  the  solution,  iluch  time  is 
saved  and  many  difficulties  are  overcome  by  separating  the  urinary 
sediment  immediately  by  means  of  the  centrifuge,  instead  of  wait- 
ing for  gravity  to  accomplish  the  same  end. 

We  have  already  noted  some  of  the  changes  which  take  place  in 
normal  urine  on  standing.  Changes  more  rapid  and  more  radical 
occur   in   pathologic   urine.        iluch   more    information    is   therefore 


■.i-2 


EXAMINATION    OK   TllK  lUlNE 


gaiiu'd  by  an  iniinediato  cxainiiiatioii  of  such  uiiiii-,  l)i'l\)ri'  casts  have 
macerated  and  soluble  substances  which  may  have  been  passed  as 
solids  have  had  time  to  dissolve,  and  before  pernicious  bacterial  ac- 
tivity has  had  time  to  destroy  contained  elements  or  to  form  new 
ones.  In  the  same  way  crystalline  substances  which  are  passed  in  a 
state  of  crystallization  may  be  distinguished  from  those  which  form 
upon  standing:.  By  the  centrifutre  the  elements  are  more  comi)letely 
separated  and  concentrated,  hence  such  as  occur  in  only  minute  quan- 
tity are  less  likely  to  escape  detecticm  than  when  collected  by  ijfravity. 


Hand   CuiUrit'iii; 


It  is  difficult  to  satisfactorily  classify  the  two  i;i'oups  of  sub- 
stances which  make  up  the  urinary  sediment.  Organized  and  unoi-- 
ganized  are  terms  frequently  nsed,  but  unorganized  does  not  in  this 
case  mean  non-organic  and  is  misleading.  Perhaps  the  division  into 
clmmic  and  histologic  sediments  is  as  aseful  as  any. 

The  chemic  substances  are  uric  acid,  the  urates,  phosphates,  cal- 
cium oxalate,  cystin,  leucin,  tyrosin,  melanin. 

The  .sediments  of  acid  and  alkaline  urine  differ  markedly.  Acid 
urine  may  deposit:  (a)  uric  acid:  (b)  acid  urates  of  sodium,  potas- 
sium, ammonium  and  calcium;  (c)  calcium  oxalate:  and  occasionally, 
'd)   hippur-ic  ncid:    ( c)   calcium    sulphate,    cystine,    leucin,    tyi-osin. 


PLATE  XXVI. 
URIC-ACID  CRYSTALS.     (Natural  color.) 


EXAMINATION  OF  THE  URINE  327 

In  such  urine  the  uric  acid  and  the  calcium  oxalate  are  crystalline,  the 
urates  amorphous  or  granular,  except  sodium  urate  which  is  sometimes 
crystalline. 

Alkaline  urine  may  deposit:  (a)  amorphous  phosphate  and  car- 
bonate of  calcium ;  (b)  crystalline  urate  of  ammonium ;  (c)  phosphate 
of  calcium  and  magnesium;  (d)  triple  phosphates. 

The  most  important  constituent  of  the  alkaline  sediment  is  the 
amorpJwus  earthy  -pliosplLates  which  are  regularly  precipitated  in 
urine  that  is  alkaline  when  voided,  as  well  as  in  urine  that  has  under- 
gone fermentation.  The  crystalline  forms  are  the  triple  phosphates, 
ammonium  urate,  calcium  phosphate  and  carbonate,  and,  under  path- 
ologic conditions,  leuein,  tyrosin  and  cystin. 

TJric  acid  crystals  oeeur  as  a  deposit  only  in  acid  urine.  Thej- 
are  deep-red  or  yellow  in  color,  prone  to  cling  to  the  sides  of  the  ves- 
sel and  can  be  recognized  by  the  trained  eye.  Cubes,  plates  and 
rhombic  crystals,  alone  or  coalesced  into  beautiful  stellates  and  ribbon 
bow-knots,  are  found  and  are  easily  recognized  under  the  lens  by 
color  and  form.  Threads  suspended  in  urine  attract  the  crystals  and 
their  tendency  to  aggregate  around  any  suitable  nucleus  explains  the 
formation  of  uric  acid  calculi,  the  most  frequent  of  all  forms  of 
gravel.  Uric  acid  may  be  said  to  be  pathologic  when  it  is  deposited 
shortly  after  the  ui-ine  is  passed.  Occurring  in  urine  which  has  stood 
ten  hours  or  more,  it  has  little  clinical  significance.  Excess  of  uric 
acid,  high  acidity,  diminished  mineral  salts  and  pigments,  favor  its 
deposit.  Over-indulgence  in  animal  food  produces  the  first  two  of 
these  factors.  Fever  favors  its  production  by  diminution  of  the  liquid 
elements  and  raising  the  acidity  of  the  urine. 

Acid  urates  of  sodium,  potassium  and  ammonium,  sometimes  of 
calcium,  occur  as  amorphous  oi*  crystalline  deposits.  The  sodium  salt 
occurs  in  the  brick-dust  sediment  so  often  seen  in  winter  urine.  It 
occurs  as  amorphous  granules  or  stellate  or  fan-like  crystalline  clus- 
ters. Its.  color  is  from  pink  to  brown,  according  to  the  amount  of 
urinary  pigment  present.  The  calcium  and  potassium  forms  are  amor- 
phous. 

Ammonium  urate  occurs  as  coarse,  spherical  masses  studded  with 
spicules.  The  colors  are  yellow  to  deep-brown  and  the  crystals  are 
known  as  "hedge-hog"  or  "thorn  apple"  crystals,  easily  recognized. 
They  are  more  apt  to  be. found  in  alkaline  urine. 

The  above  form  the    mixed    urate    sediment    so    often    seen  on 


328 


EXA.MlNATKi.N    OK   TliK   rKlNE 


the  sides  and  bottom  of  the  vessel.  The  lU'posit  is  iiiereased  hy  fever, 
wasting  disease,  oraanic  disease  of  tlie  liver,  dyspepsia  and  j;ont.  It 
is  recognized  by  its  disappearance  on  the  application  of  lieat. 

Oxalate  of  lime  occurs  in  either  aeid  or  alkaline  nrine.  It  is  often- 
est  seen  associated  with  triple  phosphates.  The  crystals  are  small, 
highly  refracting  octahedra  or  envelope  crystals  or  "dnmb-bell"  crys- 
tals and  are  unmistakable  undei-  the  microscojie.  They  disappear  on 
the   addition   of  IIC'l.      Caleiiiiii    iixnhil;'   is   a   eoii.sl  il  iieiit    i.f   cerliiiu 


Oxalate  of  Calciupi. 


vegetables  and  their  use  inci'eases  greatly  the  amount  in  noi'iii;il  iii'iiie. 
Tomatoes,  rhubarb,  asparagus  and  grapes  contain  excess  of  the  salt ; 
"greens,"  cabbage,  turnips  and  apples  contain  smaller  amounts.  Ex- 
cessive meat  ingestion  causes  excretion  of  large  amounts  of  ihe  salt. 

Ilipptiric  acid  excreted  in  large  aiuounts  by  the  herbivora,  is 
fouud  only  as  a  trace  in  normal  urine.  After  taking  benzoic  acid  or 
eating  certain  fruits,  the  crystals  are  seen,  but  have  no  clinical  signifi- 
cance. They  occur  as  colorless  prisms  with  sharply-defined  ends  and 
as  needles.  They  do  not  respond  to  the  murexide  test  as  does  lu-ic 
aeid. 

(Jalcium  sulpkalc  crystals  occur  as  radiating  needles  and  are  of 
little  importance. 

Phosphates.     The  alkaline  phosphates  are  not  fountl  in   iirinaiy 


EXAMINATION  OF   THE  URINE 


329- 


sediment.  The  earthy  phosphates  are  the  ammonio-magnesium  phos- 
phate, kno-mi  as  triple  phosphate,  and  calcium  phosphate. 

The  first  occurs  in  various  forms,  the  beveled  triangular  prism, 
or  "coffin  lids"  being  the  most  characteristic.  These  may  be  square 
or  oblong,  are  glassy  or  light-green  in  color  and  easily  recognized. 
They  disappear  on  the  addition  of  acetic  acid.  Stellate  feathery 
forms  are  less  frequent  but  easily  distinguished. 

Calcium  phosphate  is  usually  an  amorphous,  granular,  white 
deposit  which,  as  said,  is  precipitated  by  heat  and  may  be  mistaken  for- 


Fig.  77 — Triple  Phosphales.   Pine  Branch  Crystals.  Rapid  precipitation. 

albumin.  The  crystalline  form,  rarely  seen,  consists  of  rods,  separate 
or  grouped  into  wedges,  or  of  stellate,  colorless  rosettes. 

The  deposit  of  triple  phosphate  in  freshly  voided  urine  means 
ammoniacal  decomposition  in  the  lu-inary  passages,  as  pyelitis  and  cj's- 
titis.  The  deposit  of  phosphates  in  other  urine  occurs  in  convalescence, 
in  dj'spepsia,  particularly  nervous  dyspepsia,  phthisis  and  as  pointed 
out  by  Sir  William  Eoberts,  in  cancer. 

Cystine  is  rarely  seen.  It  may  occur  in  diminished  bile  secre- 
tion. It  occurs  as  opalescent  hexagonal  tablets  which  sometimes  over- 
lap each  other.  It  aids  in  forming  calculi.  A  drop  of  HCl  or  of  am- 
monia on  the  slide  causes  its  disappearance.  With  the  latter  it  re- 
appears on  evaporating  the  reagent. 

Leucin  is  rare.    It  appears  as  white  lamellj-e  or  as  yellow  spherules 


330  EXAMINATION    OK  TI1K  I'RIKE 

like  drops  of  oil.  It  rfst'iiilili's  sodimu  urtitf.  liiit  iinliUc  il  is  not  <lis- 
solved  liy  heat.  From  oil  drops  flioy  iuo  dislinuuisluMl  by  not  lioinp: 
dissolved  by  ether. 

Tjjrosiii  occurs  with  leiiciii  in  small-pox,  ty])luis,  typhoid,  in  acute 
atrophy  of  the  liver,  leiicocytha»mia  and  in  phosphor\is-poisonintr. 
It  occurs  in  yello\v-^r(>en  !.'lol)nlcs  or  as  tine  ncedlc-likc  radiatinir 
crystals. 

lUSTOLOClC  SKDl.MK.NT. 

The  histolosric  sediment  found  in  the  urine  includis  pus.  hlood. 
epithelium,  casts,  spermatozoa  and  bacteria.  .More  raicly  ai'c  found 
frntrnuMUs  of  tissue,  of  uew-trrowths.  pai'asites  or  their  eir^s. 


Fig.  78^Triple   Phospliatcs — Slow   Precipitate.    Amorphous   Urates.     A   Stellate 
Forms.     B  Coffin   lids. 

I'lis  is  the  most  frc(|uent  histoio<!ie  constituent  of  the  ui'inc  ;ui(l 
may  come  from  any  part  of  the  urinary  tract.  Pus-eoutainiuy:  urine 
is  turbid  when  voided  and  responds  to  the  tests  for  albumin.  Pus 
corpuscles  are  easily  reco.sinized  by  the  microscope  as  pale,  circular 
cells  eontaininjr  finely  granular  protoplasm  and  one  to  three  distinct 
nuclei.  Treatment  with  acetic  acid  causes  them  to  lose  their  granular 
appearance  and  the  nuclei  to  become  distinctly  visible.  Their  size 
is  nearly  double  that  of  the  red  blood  corpuscle.  When  a  quantity 
of  pus  is  treated  with  potassie  hydrate  it  dissolves  into  a  homoticueous, 


EXAMINATION   OF   THE  URINE 


331 


sticky  mass  Avliieli  will  not  flow  (Donne's  test).  In  testing  allow  the 
pus  to  settle,  then  ponr  off  the  supernatant  liquid  before  adding  the 
hydrate. 

Pus  is  frequently  mixed  with  micro-organisms  and  with  epithe- 
lium or  other"  tissue  elements  derived  from  the  locality  of  its  origin. 

Pus  derived  from  the  kidney  is  intimately  mixed  with  the  urine 
when  passed,  the  reaction  is  acid  and  the  kidney  epithelium  is  found, 
and  bladder  symptoms  are  absent.  Kenal  epithelial  ceUs  are  small, 
round  or  polygonal  with  a  single  large  nucleus.  Their  size  distin- 
guishes them  from  pus  cells. 

Pus-urine  from  the  bladder  is  alkaline  when  voided  or  quickly 


I'lg-   79 — Tyro^in   Crystals. 

becomes  so,  contains  liberal  quantities  of  mucus,  triple  phosphates  and 
flat,  large  epithelial  cells  from  the  bladder. 

Pus  from  the  urethra  may  be  squeezed  out,  or  flushed  out  with 
the  first  drops  of  lu-ine.  In  cases  of  doubt,  washing  the  urethra  before 
micturition  frees  the  urine  from  pus.  In  prostatic  disease  the  pus 
often  appears  as  long  threads  bound  together  with  mucus. 

Blood.  Blood  corpuscles  appear  in  the  urine  under  a  niuuber 
of  pathologic  conditions.  Their  bi-concave  character  and  the  alternate 
change  from  dark  to  light  of  rim  and  center,  which  takes  place  on 
focusing,  owing  to  this  formation,  aid  in  their  recognition.  After 
laving  been  soaked  for  some  time  in  the  urine  they  lose  their  sharp 


332  KXAMINATidX    111'    I'lllO   rUINK 

out  Hue.  swi'll,  iHiC'Iccr  and  resciuhlc  tlir  pus  curpuscli's.  hut  can  hr  dis- 
tinguished by  the  absence  of  uueU'i.  11'  in  doubt,  a  small  quantity  of 
the  suspected  sediment  may  be  evapoi'atrd  nn  a  wateh-plass  and  tested 
for  hosmiu.  when  small,  dark  characteristic  crystals  are  formed,  shaped 
like  little  rhombic  plates  or  rods  with  sharp  angular  ends.  The  hiemin 
test  is  simply  made  and  is  proof  positive  of  blood.  To  the  dried  res- 
idue is  added  a  few  cry.stals  of  common  .salt,  a  drop  of  glacial  acetic 
acid,  and  the  mixtni'e  boiled,  'i'lie  crystals  ai'e  seen  under  Ihe  micro- 
scope. 

The  color  of  the  urine  depends  upon  the  aumuut  of  contained 
blood  and  the  reaction  of  the  fluid.  Acid  urine  darkens  the  color, 
alkaline  urine  brightens  it.  If  in  any  quantity,  the  urine  is  markedly 
albuminous  and  cloudy.  When  blood  is  derived  from  the  bladder 
it  usually  forms  clots,  while  blood  coming  from  the  kidney  is  apt  to 
be  diffused  homogeneously,  to  be  of  dark-red  or  brown  color  and  acid 
in  reaction.  On  standing  a  brownish  sediment  is  deposited.  Some- 
times thread-like  clots  are  found.  Blood-easts  when  associated,  show 
the  source  of  the  hiematuria  to  be  the  kidney.  Acute  Bright  "s  disease, 
chronic  interstitial  nephritis,  malignant  growths,  tuberculosis,  can- 
tharides,  oil  of  turpentine  and  other  powerful  diuretics  arc  causes  of 
hajmaturia.  Injuries  are  often  followed  by  blood.  In  reiuil  abscess 
and  renal  calculus  the  blood  is  mixed  with  pus.  I  reported  a  case  a 
few  years  ago  of  death  from  purpura  hfemon-hagiea  of  the  kidneys. 
Blood  from  the  bladder  is  occasioned  by  diphtheritic  and  acute  cystitis, 
calculi,  carcinoma,  congestion.  in,iuries,  fibroids,  polypi  and  varicose 
veins  about  the  neck  of  the  bladder. 

The  urine  is  usually  alkaline  in  reaction  and  if  the  haemorrhage 
is  occasioned  by  cystitis,  pus,  mucus  and  triple  phosphates  are  found. 
Ii-regular  clots  occur,  and  the  color  is  bi'ight-red.  Blood  occurring 
in  large  quantities  may  coagulate  within  the  bladder. 

EpUhelkim  exists  in  small  quantities  in  normal  urine,  and  is  east 
otf  fi'om  the  urinary  tract  as  from  the  bodj'  surface,  the  intestines 
and  the  respiratory  tract.  It  is  increased  in  disease  of  the  genito- 
uiinary  system,  as  in  disease  of  the  other  surfaces  named.  The 
soiu-ces  from  which  the  epithelium  is  derived  can  not  in  all  cases  be 
told  by  the  form  of  the  cell.  The  large,  flat,  irregular  squamous  cells, 
W'ith  prominent  nuclei,  are  derived  from  the  bladdei'  and  the  vagina 
and  ar§  the  most  distinctive  cells  met  with  in  the  urine  The  columnar 
cells,   elongated   spindle,   cylindrical,  or   caudate   cells,    with    a    well- 


EXAMIXATIOX   OF   THE  UE1X~E 


333 


marked  nucleus  are  derivable  from  any  part  of  the  urinary  tract, 
from  the  peMs  of  the  kidneys  to  the  urethra  incliisive.  Lastly,  small, 
round  or  spheroidal  granular  epithelial  cells  with  nucleus  and  niicleo- 
lus  occur  singly  or  in  groups;  Such  (>ells  are  derived  from  the  kidney 
tubules  but  are  also  found  beneath  the  superficial  layers  of  all  the 
rest  of  urinary  tract,  hence  in  inflammations  causing  denudation  or 
exfoliations  are  not  distiactive.  They  occur  in  quantity  in  acute 
Bright 's  disease  and  often  are  associated  with  casts.  Sometimes  the 
cells  adhere  to  the  casts.     In  cystitis  the  fiat,  squamous  cells  predom- 


Fig.  So — Hyaline  Casts. 

iuate  over  the  other  varieties,  while  in  intiammations  of  the  tubes  they 
occur  very  sparsely. 

CASTS. 

Casts  are  moulds  of  the  iiriniferous  tubules.  The  mode  of  their, 
production  and  the  material  of  which  they  are  composed  are  not  yet 
ascertained.  From  their  appearance  they  may  be  separated  into  three 
classes. 

(a)  Clear  or  hyaline  casts. 

(b)  Casts  composed  of  tistologie  elements,  as  blood  corpuscles, 
epithelium  and  pus  cells. 

(c)  Those  consisting  of  waste-products,  the  result  of  tissue  change. 
The  urinary  sediment  having  been  separated  by  the  centrifuge,  a 


334 


EXA.MINATIIIN    ol'   TIIK   UKINE 


ii'W  drops  are  i)laccd  upon  a  lilass  slide  or  in  a  shallow  cell  and  well 
distributed.  "With  a  low  power  and  eoneentrated  lisiht  the  field  is 
carefully  searched.  Sometimes  hyaline  casts  which  are  exceedingly 
transparent,  hence  liable  to  escape  detection,  are  best  seen  in  a  sub- 
dued light  or  in  shadow.  They  may  be  stained  with  iodine  or  nuigenta, 
which  facilitates  the  search,  hut  ■■liters  the  iippearance  and  may  thus 
lead  to  wrong  infei-ences. 

Hyaline  casts  may  be  jierfectly  clear  and  homogeneous  or  they 
raav  show  slight  granular  sti'ucture  in  pai-ts.     Sometimes  a  fragment 


Fig.  8i — Epithelial  Casts, 
of  epithelium  adheres  and  renders  them  more  visible.  They  are  very 
pale  and  transparent,  of  varying  widths  and  lengths,  extending  in 
some  eases  clear  acro.ss  the  field.  They  are  only  found  in  albuminous 
urine  and  disappear  from  alkaline  urine  on  standing.  Wide  hyaline 
easts,  more  refracting  than  the  above  are  found,  which  exhibit  the 
amyloid  reaction.  They  were  formerly  called  waxy  casts  and  sup- 
po.sed  to  indicate  amyloid  degeneration  of  the  kidney.  Sir  William 
Roberts  refutes  this,  and  says  the  reaction  is  due  to  degenerative 
changes  in  the  casts  themselves. 

Blond  casts  occur  in  cases  of  congestion  or  ha'niori'hagc  of  the 
kidney,  hence  are  often  associated  with  blood  in  the  urine.  They  con- 
sist of  cylindrical  mouldfi,  generally  short  and  rounded  at  the  ends, 
compo.sed  of  tessellated  blood  corpuscles. 


EXAMINATION   OP   THE  URINE  335 

Epithelial  casts  are  usually  hyaline  moulds  to  which  the  epithe- 
lium is  adherent,  sparsely,  in  clusters,  or  clumps.  Sometimes,  how- 
ever, the  entire  epithelial  lining  of  a  portion  of  the  tubule  seems  to 
be  exfoliated  intact,  giving  rise  to  cylinders  composed  of  intact  epithe- 
lial cells.  They  intimate  clearly  a  catarrhal  or  desquamative  inflam- 
mation of  the  tubules  and  are  highly  important  from  a  diagnostic 
standpoint. 

Pus  casts  are  rare,  pus  corpuscles  adherent  to  hyaline,  granular 
or  epithelial  casts  are  often  seen. 

Granular  casts  are  frequently  met  with.  They  are  moderately 
broad  and  as  generally  found  one  or  both  ends  present  a  broken-off 


Fig.  82 — Granular  Casts. 

appearance.  Sometimes  one  end  is  rounded,  very  rarely  both  ends. 
The  granules  vary  from  fine  to  coarse,  and  the  colors  are  white,  yel- 
low and  dark.  The  tissue  elements  frequently  cling  to  their  surfaces, 
epithelium,  fat,  pus  corpuscles  or  leucocytes.  They  indicate  chronic 
degenerative  changes  and  are  found  in  chronic  parenchymatous  and 
chronic  interstitial  nephritis. 

Fatty  casts  indicate  extreme  chronicity  and  corresponding  de- 
generative changes.  They  are  commonly  attributed  to  the  large  white 
kidney.  The  fat  globules  are  studded  over  the  surface  of  the  cast  in 
such  a  way  as  almost  completely  to  cover  it.  The  globules  vary  in 
size  and  sometimes  small  fatty  crystals  co-exist. 


336  EXAJIINATION   OF   THE  UKINE 

Bacterial  casts  composed  of  masses  of  iiiici'ococci  indicate  urave 
iufective  processes.  Under  the  microscope  they  appear  granular,  dai-k 
in  color.  They  do  not  disappear  upon  Ihe  addition  of  alkali  or  acid 
and  when  examined  under  high  power  their  nature  is  apparent. 

With  regard  to  the  diagnosis  of  the  forms  of  kidney  lesions  from 
the  varietj'  of  the  cast  Osier  remarks:  "The  character  of  the  cast  is 
of  use  in  the  diagnosis  of  the  form  of  Bright 's  disease,  but  scarcely  of 
such  extreme  value  as  has  been  stated.  Thus,  the  hyaline  and  gran- 
ular casts  are  common  to  all  varieties,  the  blood  and  epithelial  easts, 
particularly  those  made  up  of  leucocytes  are  most  eomninn  in  tlie  aeiite 
eases. ' ' 

Cylindroids,  described  by  Thomas,  occasionally  occur  in  llic  urine. 
These  are  long,  ribbon-like  structures  with  branching  ends,  trans- 
parent, colorless  and  hyaline.  Their  exact  luiture  and  significance  is 
undecided. 

Spermatozoa  are  readily  recognized  by  their  shapes.  The  head  is 
oblong  or  oval  and  the  thin  tail  is  directly  attached.  When  alive  they 
exhibit  active  cilia-movements.  They  are  always  found  in  the  urine 
succeeding  ejaculation,  and  are  persistent  in  spermatorrhtea  and  in  the 
urine  of  confirmed  masturbators.  They  are  occasionally  rinnul  in 
acute  infections  and  in  post-epileptic  states. 

Bacteria.  Yeast  fungi  and  fission-fungi  aiv  found  in  stale  urine. 
The  latter  in  habitiial  catheter  usei's.  Ammoniacal  baeteriuria  is  the 
name  given  to  the  condition  resulting  from  ammoniacal  bacterial  fer- 
mentation within  the  bladder.  It  is  common  in  cathetei-  users.  The 
principal  agent  in  its  production  is  the  micrococcus  urea;. 

The  pus-producing  organisms,  as  well  as  the  bacteria  of  all  in- 
fective diseases,  may  be  found  in  the  urine.  Bacillus  tuberculosis  is 
found  in  tubercular  infection  of  any  part  of  the  tract,  and  the  gon- 
ococcus  in  urethral  infection.  The  first  is  searched  for  in  the  concen- 
trated sediment,  after  treating  it  .just  as  sputum  is  treated. 

Gonococci  lie  in  pairs  (diploeoeci)  within  the  pus-cells.  Tn  recent 
infection  they  are  abundant  and  easily  found  in  the  pui'ulent 
:  secretion. 


SECTION  XVI. 

THE   F/ECbS. 

A  complete  examination  of  the  faaces  includes  macroscopic,  micro- 
scopic and  chemic  examination,  and  is  of  importance  principally  as  a 
guide  to  the  state  of  assimilation  or  mal-assimilation  of  the  food. 
Such  research  is  not  always  necessary  for  diagnostic  purposes.  The 
number  and  character  of  the  movements  should  be  inquired  into  and 
whether  they  are  easy  and  natural  or  produced  by  effort  and  strain- 
ing, whether  they  are  followed  by  pain,  descent  of  the  mucous  mem- 
brane, haemorrhoids,  bleeding  or  other  unusual  phenomena.  In  the 
inspection  of  the  stool,  the  color,  odor,  quantity,  consistenc,y,  form  and 
appearance  are  noted. 

Both  the  frequency  of  the  discharges  and  the  amount  of  the  de- 
.jecta  vary  with  the  individual,  as  well  as  with  the  amount,  kind  and 
quality  of  the  food  ingested.  It  is  influenced  by  age,  sex,  habit  and 
occupation.  While  normally  the  bowels  should  move  once  in  twenty- 
four  hours  in  adults,  departures  in  either  direction  cannot  be  pro- 
nounced unnatural.  Many  individuals  habitually  have  two  or  three 
movements  per  day;  others,  a  movement  each  forty-eight  hours. 
Eegularity  and  the  resultant  effect  on  the  health  of  the  individual 
are  more  to  be  considered  than  physiologic  rule.  It  is  wiser  and  safer 
not  to  disturb  the  established  order  and  habit  of  the  bowels,  provided 
the  health  equation  remains  unaft'ected,  than  to  attempt  to  establish 
new  habits,  especially  in  adults,  but  the  inculcating  of  correctness  and 
regularitj^  in  the  child  and  the  beneficent  effects  thereof,  cannot  be 
over-estimated. 

In  nurslings  and  milk-fed  infants  the  number  of  stools  varies 
from  three  to  five  in  twenty-four  hours,  decreasing  with  age  and  mixed 
diet. 

Constipation  is  a  bodily  condition  or  habit  in  which  the  amount 
of  the  fasces  and  the  number  of  the  movements  are  less  than  normal 

Obstipation  is  the  temporary  or  permanent  absence  of  movements 
<luo  to  some  pathologic  cause,  and  is  generally  symptomatic. 


:i-iS  TUE  K.ECES 

Dim  I  had  is  an  itirn'asi'  in  the  nnnilicr  and  anniiint  nt'  I  lie  dejecta, 
usually  aet'oni|)anied  by  a  c'hani;i'  in  their  ciiarai-ti'i-. 

Painful  straining:  at  stool  is  called  l(iirsmus.  while  the  aeute. 
colicky  pains  which  accompany  diarrhcca  are  called  torminn. 

Pain,  hurninjr  and  itchinij',  succeedinjr  stool,  demand  an  exam- 
ination of  the  lower  bowel  for  the  presence  of  fissure,  ulcer,  abscess  or 
h;emori  hoids.  Cancer,  syjihilis  and  tuberculosis  of  the  lower  bowel 
may  cause  irreat  pain  with  evacuation.  In  a  ca.se  of  tuberculosis  of 
the  rectum,  under  observation,  the  pain  is  severe  and  lasts  from  one  to 
two  hours;  after  the  movement.  Descent  of  the  bowel  and  lucmorrhoids 
are  readily  detected  by  examination.  Kectal  prolapse  in  children  is 
not  infrequent. 

Inspccliiiii.  Tlie  niiruial  enlor  of  the  fa'ces  is  hi'owii  or  yeli<iw- 
brown,  but  varies  with  the  food  eaten.  In  children  the  milk  stool  is 
lisrht-yellow.  Chocolate  and  corn  s.vrup  impai-t  a  dark-bruw  ii  or  black 
color  to  the  de.jecta.  Certain  green  vegetables,  as  spinach  and  si)routs 
produce  green  stools,  due  to  the  contained  chlorophyll.  The  green 
color  seen  in  infantile  diarrhoeas  is  due  to  butyiie  and  lactic  acid 
fermentation,  acting  on  the  bile  coloring  matter.  In  adults  green 
stools  may  sometimes  be  attributed  to  a  mieioscopic  vegetaljle  growth 
known  as  chlorococcus.  !\Iitierals  such  as  iron,  bismnth,  lead  and 
manganese,  taken  1)>-  the  mouth,  impart  a  black  color  to  the  stools, 
due  to  the  formation  of  the  sulphides  of  these  metals,  ^lottling  is  not 
infrequent  but  has  no  special  significance.  Fresh  hlood  imparts  a 
bright-red  color  to  the  faeces,  which  changes  to  dark-brown  when  the 
matter  is  retained  within  the  bowel.  If  i-etained  for  a  considerable 
time  the  stools  become  black  and  tarry,  due  to  ha^natin.  Clay-color 
indicates  lack  of  bile.  The  normal  color  depends  upon  the  amount  of 
bile-pigment  present  and  the  amount  of  change  the  latter  has  under- 
gone, the  results  being  bilirubin,  biliverdiii  and  their  oxydation 
product  choletelin,  or  their  reduction  product  hydrobiliruliin  and 
stercobilin. 

The  fcetor  depends  in  a  large  measure  on  the  presence  of  indol 
and  skatol  which  are  the  outcome  of  putrid  bacterial  activity:  the 
decomposition  of  albuminoid  substances,  and  upon  the  presence  of 
certain  fatty  acids.  Sulphuretted  hydrogen,  traces  of  hydrogen  phos- 
phide, ammonia  and  organic  bases  contribute  to  the  odor.  In  some 
catarrhal  diseases  and  in  dysentery  the  odor  is  excessivelv  offensive. 


THE  F^CES  339^ 

In  gangrene  it  may  be  putrefactive  or  cadaveroiis.    Infantile  and  sum- 
mer diarrhoeas  have  a  sour  odor  due  to  fermentative  changes. 

The  quantity  of  faeces  evacuated  in  a  day  depends  upon  the  diet,, 
being  greater  with  a  vegetable  or  starchy  diet  than  on  meat  diet.  The 
average  quantity  is  about  150  grams  a  day,  varying  between  60  and 
250  grams  (Yeo),  of  which  about  75  per  cent,  is  liquid.  The  more 
rapid  the  passage  of  the  ingesta  through  the  bowels,  the  greater  the 
amount  of  fluid  which'  remains  with  the  fjEces,  which  explains  the 
diminished  consistency  of  stools  caiTsed  by  intestinal  irritants  and 
substances  which  stimulate  peristalsis.  In  diarrhoeal  diseases  the 
amount  of  fluid  is  miich  increased. 

The  consistency  of  the  normal  stool  is  such  that  the  passages  are 
formed  and  firm.  A  thick,  mushy  consistency  is  more  usual  in  sum- 
mer time  when  vegetables  and  fruits  are  largely  indulged  in.  As  said, 
the  consistency  increases  with  retention.  Experiments  made  by  myself 
to  determine  the  time  required  for  non-irritating  substances  to  pass 
through  the  normally  active  healthy  bowel,  seemed  to  establish  thirtj^- 
six  hours  as  a  fair  average.  H.  C.  Wood  states,  on  what  authority  I 
Imow  not,  that  only  four  hours  are  required  for  the  contents  of  the 
bowel  to  pass  from  the  pylorus  to  the  caecum. 

Although  the  reaction  of  the  large  intestine  is  markedly  acid,  due 
to  acid  fermentation,  yet  the  reaction  of  normal  fffices  is  neutral, 
sometimes  alkaUue,  more  rarely  acid.  The  allvalinity  is  due  to  am- 
moniacal  fermentation,  and  is  increased  by  meat  diet,  the  acidity  to 
lactic  and  butyric  acid  fermentation,  but  sometimes  acetic  and  pro- 
pionic acids  are  found.  Vegetable  diet  assists  in  their  production. 
Much  mucus  renders  the  stools  alkaline.  The  acid  reaction  of 
nurslings  and  milk-fed  infants  is  due  to  lactic  and  free  fatty  acids. 

Composition.  The  fteces  are  composed  of  the  luidigested  parts, 
of  the  food,  the  xiseless  and  injurious  portions  of  the  various  secre- 
tions, decomposition  and  microbie  products  and  gases. 

Among  the  first  are  found  yellow  elastic  tissue,  tendons,  nuclein, 
epidermic  and  horny  substances,  vegetable  fiber,  chlorophyll,  giims, 
resins,  cellulose  from  vegetable  sources,  particles  of  food  which,  from 
imperfect  mastication  have  not  been  acted  upon  by  the  digestive 
juices,  alimentarj'  substances  which  are  assimilable,  but  of  which  an 
excess  has  been  taken,  especially  fats  and  starches,  insoluble  salts,  as 
silicates,  sulphates  and  phosphates  of  calcium  and  ammonium-mag-- 
nesium  phosphate. 


34(1  TUE  P.«CES 

111  iiiixctl  diot  tlu'  waste  soeretions  excL-ed  the  residue  ilerivril  from 
the  injresta.  and  eousist  of  intestinal  iiiueus,  epithelial  cells,  suh- 
stanees  whieh  failed  of  absorption,  as  decomposed  bile,  coloring  iiiat- 
tei-s  and  inorganic  salts;  free  fatty  acids  from  acetic  up  to  palmitic 
acid,  butyric,  lactic,  cholalic  acid  and  cholesteriii:  indol.  skatol,  cresol. 
phenol,  leucin,  tyrosin,  each  ni;i\-  ;i|ipc;ii'  nndn-  ccrliiiii  cdiidit  inns. 
The  gases  expelled  are  CO,,  Cll,,  II.  X.  11, S.  'I'll,'  .\  is  i\vvnri\  froiu 
swallowed  air,  the  rest  arise  in  tiu'  cnursc  o\'  ilccomposilion. 

The  meconium  is  the  naiiu'  gi\fn  lo  Ihr  contents  of  the  intcsliiif 
which  accumulate  during  fcctal  lil'r.  Il  is  usually  evacuated  soou 
after  Itirth.  Its  color  is  dark-green  or  brown  and  its  consistency  salve- 
like or  tarry.  It  is  acid  in  reaction  and  devoid  of  fiecal  odor.  It 
consists  of  epithelial  cells  in  abundance,  cholesterin,  fats,  fatty  acids, 
mucin  ancrbile-coloring  matters. 

The  stools  of  milk-fed  infants  contain  tats,  fatty  acids,  casein, 
epithelial  cells,  lactate  of  calcium,  mucin,  coloring  matters  and  bac- 
teria. In  infants  fed  on  cow"s  milk,  the  casein  is  much  increa.scd  over 
that  of  breast-fed  infants. 

Acholic  stools  arc  waiitiiiL;-  in  bile.  The  coloi'  is  blue-cla\-  or 
chalk-paste.  They  are  very  fcetid  and  contain  large  quantities  of  fat. 
Suppression  of  the  pancreatic  secretion  is  followed  by  fatty  stools, 
and  their  persistence  should  be  viewed  with  grave  suspicion. 

Diarrhwal  stools  contain  excess  of  water.  When  due  to  catarrhal 
conditions  they  contain  epithelium  and  much  mucus.  In  acute  eases 
the  latter  imparts  character  to  the  passages,  which  are  named  mucous 
■.stools,  iledicines  which  hasten  peristalsis  produce  the  same  watery 
evacuations.  Further,  the  activity  of  the  peristalsis  prevents  absorp- 
tion, hence  hurries  down  much  unassimilated  food  substance. 

The  characteristic  typhoid  stool  is  ott'ensive.  abundant,  thin,  gray- 
ish-yellow, granular,  and  in  appearance  and  consistency  resembles 
pea-soup.  The  reaction  is  allcaline.  They  sometimes  contain  blood, 
shreds  of  necrotic  tissue,  and,  generally,  ammonium-magnesium  phos- 
phate. Ou  standing  they  separate  into  two  layers,  an  upper,  serous 
layer  containing  albumin,  and  a  lower  layer  containing  the  residue, 
food  and  epithelium.  After  the  end  of  the  first  week  is  found  the 
Eberth  bacillus  and  a  poisonous  base  known  as  typhotoxin.  I^lood 
and  necrotic  shreds  are  recognized  by  the  microscope. 

Cholera  stools  are  ever  likened  to  rice  water;  thin,  turbid  or 
translucent.     Koch's  spirillum   or  coma  bacillus  abounds,  especially 


THE  F.ECES  <341 

early  in  the  disease.  Epithelial  ceUs  in  abundance  are  seen  under  the 
microscope.  The  discharges  contain  nitriies  which,  with,  the  indol  of 
the  stool,  gives  a  blood-red  color  on  the  addition  of  dilute  sulphuric 
acid.    The  reaction  is  diagnostic. 

The  discharges  of  dysentery  are  peculiarly  foetid,  voided  with 
great  tenesmus,  tinged  with  blood,  contain  much  mucus,  and,  in  old 
cases,  fragments  or  sloughs  of  mucous  membrane  and  pus.  Amoeba 
coli  characterize  the  form  known  as  tropical  dysentery.  Fresh  dejecta 
must  be  examined  iipon  a  warm  stage  in  order  to  demonstrate  their 
presence.  The  fibrinous  casts  and  shreds  of  mucus  should  be  examined 
by  floating  ia  water. 

Gail-stones  and  enteroliths  are  sometimes  found.  "When  gall- 
stones are  suspected,  the  stools  should  be  passed  into  a  cheese-cloth 
"crab-net"  over  a  wire  frame,  placed  in  the  closet,  then  washed  in 
running  water.  The  stones  are  recognized  by  their  hardness,  shiny 
appearance,  color  and  facets,  giving  them  an  uncut  crystal  appearance. 

Enteroliths  are  solidified  food  concretions  of  varjing,  iisually 
small,  size.  Seeds,  animal  parasites,  eggs  and  larvje  are  often  found 
in  the  fsces. 

Pus  occurs  in  cases  of  abscess  rupturing  into  the  tract  or  in 
destructive  inflammations  of  the  bowel  itself,  as  in  dysentery. 

In  cases  of  tuberculous,  syphilitic  or  cancerous  ulceration  pus  is- 
mixed  with  tissue  shreds  and  blood. 

Microscopic  Examination.  Wlien  very  thin  the  faeces  can  be  ex- 
amined without  dilution,  or  a  small  portion  may  be  thinned  with 
water,  spread  on  a  cover  glass,  dried,  fixed  and  stained  in  the  usual 
-.vay.  Bacteria,  pus,  blood,  epithelial  cells,  crystals,  and  detritus  are 
thus  recognized.  In  conditions  of  intestinal  suppuration,  leucocytes 
are  found.  The  crystalline  substances  encountered  are  fat  crystals, 
phosphatic  cry.stals,  oxalate  of  lime,  sulphate  of  calcium  and  occa- 
sionallv  others. 


SECTION   XVll. 


THE  ROEN TGbN  RAY  IN  DIAGNOSIS. 

The  X-ray  contributes  vei'v  considerably  to  the  science  of  diag- 
nosis and  in  some  cases,  at  least,  affords  aid  at  just  the  point  where 
other  methods  are  imperfect  or  totally  inadequate.  Hence  it  is  to  be 
regretted  that  the  system  is  not  of  more  xiniversal  applicability.  In 
private  practice  its  use  is  not  yet  extensive.  Iiiil  at  present  all  large 
hospitals  and  most  smaller  in.stitutions.  as  well  as  many  physicians' 
offices,  are  equipped  with  the  necessary  ajiparatiis. 

Since,  however,  for  a  long  time  to  come  the  urcatrr  luiinlicr  of 
examinations  for  a.scertaining  the  pliysieal  condition  of  jiatients  must 
he  conducted  without  its  aid.  jiractitioners  will  do  well  to  cultivate 
and  i^ractise  the  older  methods  of  diagnosis,  even  in  the  instances  to 
be  described  in  which  its  use  affords  us  most  comfort  by  reason  of  its 
certainty. 

The  static  machines  constructed  for  office  use  ai-c  fi|uip|)ccl  with 
the  necessary  X-ray  apparatus,  'i'lu'v  arc  expensive,  bulky,  station- 
ary, but  efficient.  At  present  the  work  is  generally  confined  to  men 
of  special  training,  but  experience  is  the  only  requisite. 

For  purposes  of  diagnosis  in  di.seases  of  the  chest  a  high  pene- 
trating power  is  unnecessary  and  less  efficient  than  one  of  lower  power 
since  the  latter  renders  less  transparent  the  organs  which  we  most 
wish  to  examine,  by  reason  of  such  solid  organs  obstructing  the  softei-. 
less  penetrating  rays.  This  is  brought  about  by  using  Crooke's  tubes 
of  less  perfect  vacuum  than  those  necessar>'  for  viewing  the  Ixmes 
and  large  joints.    Such  tubes  are  technically  called  soft  tubes. 

The  Examination.  The  examination  may  be  direct,  by  the  use 
of  the  fluoroscope,  to  which  proceeding  the  name  radioscopy,  or  Ront- 
goscopy,  is  given :  or  the  examination  may  be  indirect,  by  making 
radiographs  or  plates  from  which  prints  are  made.  The  latter  process 
is  called  radiography. 

A  fluoroscope  is  simply  a  ]iiece  of  cai'd-board  coated  with  a  Huor- 


THE    ROENTGEN    RAY    IN    DIAGNOSIS 


343 


eseent  salt — platinocyanide  of  barium  is  tlie  best — and  fitted  into  a 
frame  like  the  stereoscope. 

In  general  hospital  work  the  examinations  are  made  almost 
entirelj-  with  the  fluoroscope  as  the  results  are  immediate,  and  in  the 
hand  of  a  practised  examiner  much  more  information  upon  certain 
necessaiy  points  is  vouchsafed  tlian  by  the  pictures.     But  the  direct 


Fig.  83 — Normal  Chest. 


The  natural  bulge  in  aorta  referred  to  in  text  is 
at  B. 


examination  rec(uires  that  the  patient  be  submitted  to  the  ordeal  for 
a  much  longer  time  than  is  necessary  to  secure  tlie  photographic 
pictiu-e,  and  is  tiresome  likewise  to  the  examiner.  In  ea.ses  of  severe 
illness  this  is  a  point  worthy  of  considei'ation.  On  the  other  hand  it 
is  the  only  way  in  which  pulsations,  the  movements  of  organs,  and 
changes  in  the  position  of  fluids  may  be  appreciated. 

As  intimated,  experience  and  good  judgment  play  no  small  part 
in  forming  correct  conclusions  by  this  method,  since  only  by  practice 
and  experience  the  relative  position,  size  and  qualities  of  the  organs 


;j44  TiiK  K(ii:nt(.;en  ray  in  diagnosis 

in  tlie  shadinv  pirlurcs  can  In'  Icarinnl.  as  all  llu'se  vary  with  the 
distance  between  patient  and  li^lit,  and  other  t'aelins. 

Radiojrraphy  is  most  useful  in  doubtful  and  disputed  cases;  the 
lu-ints  have  a  certain  medico-legal  value,  can  be  used  for  measure- 
ments and  comparisons,  and  when  successive  pictures  are  obtained 
show  jiositive  results  of  treatment  or  of  the  advance  of  disease,  and 
furnish  us  with  permanent  records. 

Since  the  improvements  in  apparatus  and  technique,  the  neces- 
sary exposure  has  been  so  shortened  that  at  present  satisfactory  pic- 
tures are  obtained  by  exposures  of  less  than  a  second  (von  Ziemssen). 

Fluoroscopic  Examination :  Badloscopy.  The  examination  is  con- 
ducted in  a  (laik  room  and  is  simplest  and  most  satisfactory  with  the 
patient  erect,  as  in  this  position  only  are  the'  normal  relations  pre- 
served. The  Crooke's  tube  is  placed  behind  the  patient  in  the  median 
line  at  a  distance  of  about  two  feet,  on  a  level  with  the  part  to  be 
examined.  A  fenestrated,  adjustable  metallic  screen,  or  a  Beck's 
diaphragm,  placed  between  the  tube  and  the  patient  is  useful  for 
concentrating  the  light  on  a  particular  point  and  for  cutting  oft" 
extraneous  rays.  In  case  the  patient  is  unable  to  stand,  the  tube  is 
adjusted  under  a  canvas  cot  on  which  he  rests.  Tlic  Huoicscnpc  is 
placed  directly  in  front  of  the  chest  walls. 

Rontgen  ray  burns  are  the  result  of  too  long  or  too  oft-repeated 
exposures.  Restricting  the  single  exposures  to  five  niiinitcs.  and  not 
repeating  these  oftener  than  at  iiitcr\-als  of  every  tlircc  da>-s.  i^,  said 
to  be  a  safe  limit. 

THE  THORAX. 

The  healthy  lungs  do  not  perceptibly  iii1crec|>l  tlic  rays  hence 
theii-  image  appears  only  as  a  faint  shadow.  The  vei'lebral  coiunm, 
the  ribs,  clavicles  and  sternum  are  plainly  seen.  The  pericardium, 
the  outlines  of  the  heart  and  its  movements  are  distinct.  The  great 
vessels  are  less  distinct,  but  visible.  The  movements  of  the  diaphragm 
are  distinct  and  when  restrained  the  limitation  may  })e  detected  by 
the  practised  observer.  In  children,  and  genei'aliy  in  adults,  the  bifur- 
cation of  the  trachea  may  be  seen. 

The  apex  of  the  heart  .shows  sliai'|)ly  diii'ing  deep  inspiration.  A 
bend  or  protuberance  upon  the  left  of  the  aorta,  above  the  pericardial 
sac,  resembling  an  aneury.sm  is  often  seen  and  might  be  mistaken 
readilv  for  such  a  srowth. 


THE    ROENTGEN    RAY    IN    DIAGNOSIS 


345 


Fig.  84 — Small  Aemirysm  of  Aorta.     Johns  Hopkins  Hosp..  Dr.  Baetjer. 


THE    ROENTGEN    RAY    IN    DIAGNOSIS  347 


Fig.   85 — Disseminated    Pulmonary   Tuberculosis,    both    kmgs.      Johns    Hopkins 
Hospital,  F.  H.  Baetjer. 


THE    ROENTGEN    RAY    IX    DIAGNOSIS  349 

The  unequal  heights  of  the  two  sides  of  the  diaphragm  is  strik- 
ingly seen,  the  right  side  being  always  the  higher.  This  shows  best 
during  deep  inspiration.  In  case  of  hypertrophy  of  the  heart  the  left 
diaphragm  is  sunken  below  the  normal  plane,  while  in  early  tubercu- 
losis Williams  finds  the  structure  abnormally  high. 

Diseases,  injuries  or  malformations  of  the  vertebrae,  supernumer- 
ary ribs,  or  foreign  bodies  within  the  thorax  are  easily  recognized. 

Cardiac  hypertrophies  and  dilatations  not  only  can  be  recognized 
but  ditferentiated  (vou  Ziemssen).  Displacements,  effusions  into  the 
pericardium  and  aneurysms  of  the  organ  are  made  out,  as  are  also 
mediastinal  tumors. 

WMle  the  healthy  lungs  give  almost  no  image,  yet  diseased  con- 
ditions are  fairly  well  brought  out  by  the  rays.  Pulmonic  solidifica- 
tions,  especially  deep-seated  foci  of  pneumonia  almost  impossible  to 
demonstrate  otherwise,  appear,  as  do  tuberculous  solidificatious, 
vomicae,  abscesses,  bronchiectasis,  atelectasis  and  calcifications. 

Cavities  with  thickened  walls  are  seen  as  shadows  surrounded  by 
lighter  areas.  Incipient  tubercular  lesions  show  but  little,  and  it  is 
doubtful  if  they  can  be  recognized  by  the  rays  before  they  are  demon- 
strable by  other  means. 

Effusions  into  the  pleural  cavities  are  markedly  opaque,  and  the 
movements  to  which  they  are  subject  are  strikingly  shown.  Serous 
effusions  appear  more  opaque  than  do  those  of  pus.  The  boundary 
line  between  eft'usion  and  air  in  hydropneumothorax  is  distinct.  Pul- 
monary retraction  resulting  from  old  pleurisy,  as  well  as  thickening 
and  deposits  upon  the  pleural  membrane,  all  show  in  the  plates. 

Irregular  movements  of  the  diaphragm  and  restrictions  of  its 
excursions  are  easily  studied.  The  diaphragm  separates  from  the 
heart  during  deep  inspiration. 

During  forced  inspiration  the  lung  shadow  is  diminished.  In 
emphysema  the  lung  shadow  is  fainter  still  than  in  normal  lungs. 
The  heart  ob.structs  the  shadow  of  that  portion  of  the  lungs  which  it 
covers. 

Sclerosis  of  the  deep  vessels  can  be  recognized  only  by  the  x-ray 
picture.  The  position,  size,  shape  and  type  of  intrathoracic  aneurysms 
are  better  told  by  the  skiagraph  than  by  percussion  and  auscultation, 
and  repeated  instances  are  recorded  in  which  they  have  been  discov- 
ered by  this  meaps  when  their  presence  was  unsuspected.  Pulsation 
distinguishes  them  from  solid  tumors  of  the  same  area. 


35U  lllK     IMKNTCKN     UAV     IN    DIAGNOSl!- 


•rilK  AUDO.MKN. 


In  diseases  of  tlu'  alidoincn  a  sonu'what  hanliT  liihc  than  lliat 
used  in  chest  work  is  desirable.  Skiairrapliy  irives  the  best  results. 
The  solid  liver  shows  best:  the  intestines  are  discernible  only  occa- 
sionally, but  their  contents  show.  The  trianirnlar  psoas  nuisde  can 
be  seen.  The  outline  of  the  stomach  is  shown  by  coatiufi  its  walls 
with  a  substance  impenetrable  by  the  rays,  as  subnitrate  of  bismuth, 
or  by  the  introduction  of  a  flexible  steel  wire  covered  with  rubber. 

Tumors  of  the  stomach  show  only  when  of  considerable  density. 

Radiosrraphs  of  the  intestines  are  obtained  in  the  same  manner 
as  has  been  suggested  for  taking  skiagraphs  of  the  stomach.  One 
ounce  of  bisnuith  s\ibuitrate  is  suspended  in  a  quart  of  milk.  The 
skiagraph  of  the  stomach  nuiy  be  taken  immediately  after  its  inges- 
tion. Six  hours  later  the  pictin-e  of  the  small  intestine  is  lakeu: 
twelve  to  twenty-four  hours  later  the  colon  shows  best  in  the  print. 

Recent  examiners  are  all  in  accord  in  stating  that  the  i)osition  of 
the  stomach  as  described  in  the  text-books  is  incorrect.  The  vertical 
position,  as  referred  to  in  the  description  of  the  organ  in  the  section 
on  anatomy,  and  the  jiosition  which  has  usually  been  considered  and 
described  as  ptosis  or  moderate  prohipse,  are  most  often  observed. 
The  same  may  be  said  of  the  intestines:  what  formerly  has  been  re- 
garded as  prolapse  of  the  colon  is  more  commonly  found  than  the  so- 
called  normal  position. 

The  examinations  sliow  that  dilatation  and  prolapse  are  fre- 
((uently  met  with,  especially  in  women. 

;More  extended  research  will  probably  change  many  of  our  preva- 
lent ideas  on  these  topics. 

The  spleen  appears  indistinctly,  as  do  also  the  icidueys.  They 
appear  in  the  radiographs  but  are  seldom  seen  by  the  iiuoroseope. 

Diseases,  fractures  and  displacements  of  the  lumbar  verlel)r;e: 
calculi  of  kidneys,  ureter,  bladder  and  prostate,  and  those  of  the 
hepatic  duct  and  gall  bladder  are  demon.strable. 

The  .size,  shape  and  position  of  the  liver  are  easily  studied  by  the 
rays,  and  abscesK,  when  present,  is  revealed. 

Biliary  calculi  are  difficult  to  .show  in  the  picture  and  much  de- 
pends on  their  c.i/mposit".i)n.  but  in  recent  years  the  difficulties  havi' 
been  snccessfully  overcome. 

Plydronephrosis  and  cysts  of  the  kidney  have  been  demonstrated. 


THE    ROENTGEN    RAY    IN    DIAGNOSIS 


351 


Fig.    86 — Aneurysm.      Johns    Hopkins    Hospital,    Dr.    Baetjer. 


THE    ROENTGEN    KAY    IN    DIAGNOSIS 


;!r)3 


Fig,  Sy — Aneurysm  of  Aorta.     Johns  Hopkins  Flospital,  F.  H.   Baetjer 


THE    ROENTGEN    RAY    IN    DIAGNOSIS  355 

but  it  is  in  calculi  of  these  organs  that  the  pictures  are  of  paramount 
usefulness,  since  the  absence  from  a  good  plate  of  indications  of  their 
existence  justifies  a  negative  dia^'nosis  in  most  cases.  Ureteral  and 
vesical  calculi  also  can  be  skiagraphed. 

The  Eontgeu  ray  diagnosis  of  renal  calculi  is  more  satisfactory  in 
children  than  in  adults.  The  most  important  factors  are  the  size  and 
composition  of  the  stone,  the  size  of  the  subject  under  examination, 
and  the  condition  of  the  kidney,  according  to  Smart.  He  says  that 
pure  uric  acid  stones  are  the  most  difficult  to  detect ;  pui-e  phosphatic 
stones  ranking  next.  A  combination  of  ui-ic  acid  with  phosphate  or 
oxalate  of  calcium  is  more  easily  detected,  while  pure  oxalate  stones 
are  the  most  opaque  to  the  rays.  Occasionally  a  collection  of  pus  or 
induration  of  the  organ  may  obscure  the  shadow.  I'he  intestines  of 
the  subject  should  be  well  emptied  by  enemas  and  purgatives,  and  all 
clothing  removed  from  the  parts  of  the  body  wliich  are  to  appear  in 
the  negative. 

Breathing  should  be  restricted  by  an  abdominal  binder  in  the  case 
of  children,  as  the  movements  of  the  kidnej^s  interfere  with  the  shariD- 
uess  of  the  pictures.  Adults  may  be  placed  face  downwards  on  a 
canvas  cot,  the  weight  of  the  body  being  sufficient  to  limit  the  respira- 
tor}^ excursions.  In  this  case  the  tube  is  placed  under  the  cot,  and  the 
plate  on  the  patient's  back,  as  before  described.  Both  kidneys  and 
both  ureters  should  be  included  in  the  picture.  In  case  of  doubt,  the 
exposure  should  be  repeated  a  few  days  later,  the  conditions  being  as 
nearly  similar  as  possible. 

Foreign  bodies  in  any  part  of  the  abdomen  are  easily  located, 
especially  if  metallic,  as  nails,  tacks,  coins  and  the  IMurphy  button.. 


INDEX 


Abdomen,   255 

alterations  of,  255 

anatomy  of,  256 

auscultation,   256,    264 

enlargements,  260 
causes  of,  260 

general    considerations,    255 

inspection,  259,   280 

methods  of  examining,  259 

palpation.   261 

percussion.   262,   280 

planes  of  reference.  256 

shape  of.  259.  271 

topography,  256 

tumors  of,  275.  277 

retraction  of,  260 
Abdominal  pain,  262 
Abscess  of  fauces,    loi 

of  liver,  281,  283 

of  lung,    132,   140 
Absorption,  gastric,  304 
Acetic  acid,  298 

detection  of.  301 
Acetonuria,   324 
Achromatophilic,  238 
Acids    in  gastric   contents,    300 

acetic,  245 

detection  of.  300 

butyric.    300 

hydrochloric.  296 

estimation  of,  301 

lactic.   298 

detection  of,  300 
Acidity,   total  gastric,   300 
Addison's    disease.   254.   302 
Adherent  pericardium.  195 
Adventitious  sounds.  81.  176 
Alar   chest,   31 
Albumin,  317 

coagulation  test,  319 

Heller's  test  for,  318 

Potassium  ferro-cvanide   test   for. 
318 


Albuminuria,    199,   317 

cyclic,    317 

lesions  causing,  317 
Albumoses,  303 

test  for,  303 
Amylolysis,  303 
Amoeba  coli,  341 
Anacrotic  pulse,  65 
Anaemia — 

in  Addison's  disease,  254 

dyspnoea   of,    100 

in   gastric  carcinoma,   250 

m  Hodgkin's  disease,  254 

pernicious,   250 

in  purpura,  254 

splenic.   251 
Anatomy  of  aorta,  228 

of  chest,   -Zi 

of  heart,   159 
Anasarca,  cardiac,  211,  294 

general,  294 
Aneur\-sm,  228 

of  ascending  aorta,  230 

Bramwell's  classification,  230 

of   descending  arch,  231 

differential  diagnosis,  232 

of    innominate,   232 

physical  signs,  229 

pressure  symptoms.  230 

special    diagnostic    symptoms,      232,. 
235 

Smith's  sign,  232 

thoracic,  228,  231 

of  transverse  arch.  231 

tracheal  tug,  232 

x-ray  diagnosis  of.  49.  349 
Aneurysmal  bruit,  230 

thrill,   230 
Amphoric  breathing.  81 

resonance,  75 

voice,  85 
Aorta,  aiiatomy  of.  36 
Aorta  area,  183 

associated  murmurs.  212 


358 


Aorta — 

incompetency,  183.   186 
mechanism  of,   210 

murmurs  of,  185 

physical  sign,  Jii 

notch,    66 

obstruction,   183 

stenosis,  186,  214 

diagnosis  of,   216 

stenosis   and   incompetency,  217 
mechanism  of,   217 
physical  signs  of.  217 

thrill,    215 
Apex  of   heart,    160 

method   of   locating,  55,   162 
Area    of   absolute    cardiac    dullness. 

167 
Arhythmia,    58 
Apoplexy,  pulmonary.   139 
Appendicitis,    2O0,    276 

palpation  in,  271 

diagnosis   of,   278 

physical   signs  of,  276,  278 

leucocytosis  in,  240 

tumor  in,  279 

varieties,  276 
Arterial  murmurs,  62 
Ascites,   294 

causes,  294 

hepatic  cirrhosis,  285 

in    hepatic   cancer,   285 

diagnosis   of.   295 
Associated  cardiac  murmurs.   179.  2 
Asthma — 

bronchial,   no 

cardiac,  214 

renal,    no 
Atrophy  of  optic  nerve,  89 
Auscultation,  76 

of  heart,  170 

immediate,  76 

mediate,  76 

of  voice,  84 
Auscultatory   percussion,   26 
Axillary  regions,   33,   42 

boundaries,  33 

contents,  42 

divisions,  34 

B 

Bacelli's   sign,   86,    121 


Bacteria   of  bronchiectasis,    113 

of  broncho-pneumonia,   136 

in   gastric   carcinoma,   305 

of  pneumonia,   134 

in   urine,  336 
Barrel   chest,  30 

causes  of,  30 
Basophiles,   23S 
Bell  sound,  86 

in  pneumothorax,  86 
Bellows  murmur,   291 
Bile   pigment  in  urine.  324 

Gmelin's   test  for,  324 
Bizzozero's  plaques,  236 
Bladder,   290 
37.Boas-Oppler  bacillus.  305 
Boas'  test  meal,  298 

test   for  HCl,  299 
Blood,   examination  of,  236 

in  abdominal  diseases,  255 

in    Addison's   disease,   254 

in  chlorosis,  249,  252 

corpuscles   of,   237,  238 

counting   apparatus,    241 

diluting  fluids,  244 

films,    246 

fixation  of,  246 

in  gastric  carcinoma,  305 

haemoglobin  of,  249 

in   Hodgkin's   disease,   254 

in  intestinal  obstruction,  274 

in  lobar  pneumonia,  135 

in  lymphatic  leukxniia,  251 

malarial  organism   of,  248 

normal  elements  of,  236 

nucleated  red  cells  of,  237 

in    pericarditis,    241 

in   pernicious   anaemia.  252 

in   phthisis,    157,   254 

plaques   of,   2,36 

in  pneumonia,   1.35 

preparations,  246 

in  purpura,  254 

in  splenic  leidvremia,  251 

in    spleno-mcdullary    leukxmia.    241, 
251 

staining,  247 

in  stool,  274 

technique,   246 

test  for  presence  of,  331 


359 


Blood- 
in    urine,    331 

color  imparted  to,  332 
Breathing — 

(see    also    Respiration) 

absent,  79 

amphoric,  81,   153 

bronchial,   TJ,   79,   119,   151 

broncho-vesicular,  49,  78,  80,   ]  ly, 
130,    148 

cavernous,  80,   152 

diminished,    79 

in  pneumonia,   130 

in  phthisis,    148 

puerile,  78 

supplemental,  78,   130 

tracheal,   'J'J 

tubular,    49.    77,    13"! 

t>-pes,  48 

vesicular,  78 
Broadbent's  sign,   195 
Bronchi,  division  of,  41 
Bronchial  stenosis,    114 

asthma,   no 
Bronchiectasis,    in,    145 

differential  diagnosis,   114 

physical    signs,    112 

varieties,   in,   145 
Bronchitis,    106 

acute,    106 

capillary,  107 

chronic,   loS 

physical  signs  of,   106,   107 

sputum   of,    107 
Broncho-pneumonia,    136 

diagnosis  of,  139 

from  acute  tuberculosis,   139 

physical  signs,  13S 

terminations,  137 

tuberculous,  143 

physical   signs   of,    144 
Bronchophony,    85 

in  bronchiectasis,   113 

in  broncho-pneumonia,   138 

in  pleurisy,    122 

in  pneumonia,  131 

in  pulmonary  tuberculosis,   151 
whispered,  86 
Bruit,   aneurysmal,  230 
de  cuir  neuf,  191 
de  diable,  61 


Bruit— 

de  galop,   191,  225 

in   phthisis,    148 

de  souffle,  212,  291 
Butyric  acid,  detection  of,  300 


Cancer,   gastric,  250,   269 

diagnosis    from    liver     enlargement. 

286 
hepatic,   284 
of   rectum,  2S2,   33S 
Canter    rhythm,    191,    225 
Calculi,   diagiiosis  by   x-ray,  355 

intestinal,    272,   282 
Capillary   pulse,   63 
Caput  Medusre,  60,  294 

in    atrophic   cirrhosis,    285 
Carbohydrates,   320 

in  urine,  320 
Carcinoma,   gastric.  250,  269 
acetone    in.   324 
of  liver,  284 
rectal,   282,   338 
urine   in,   32^ 
Cardiac    cycle,    159 
changes  in,    189 
defects,  congenital,  222 
diastole,    159 
dullness,  n,    167 
impulse,   displaced,    168 

normal,   169 
lesions,  order  of  frequency,   178,  22T 

in  tuberculosis,  151 
murmurs,   177   (see  Murmurs) 
systole,  159 

valves,   location   of,   160,    174 
reduplication,  176 
sounds    of,    174 
Cardiac  orifice   of  stomach,  46,   266 
Cardio-respiratory   murmur,    187 
Case — 

records,  19 
value  of,   19 
taking,   20 
Casts,  333 

bacterial,  336 
blood,  332,  334 
epithelial,   335 
fatty,  335 
fibrinous,  94 


:{(i(i 


CastS' — 

granular.  335 

hyaline,  334 

pus,  335 

urinary.  333 
Cataract.  90 
Catarrh,  intestinal.  272 
Cavities.    145 
Cells,   behavior    to   dyes.   238 

mast,   238 
Chemical   dyspnoea,  100 
Chest,   adult,  28 

alar,   31 

alterations  produced  by  disease.  48 

anatomy,  32 

barrel.  30 

emphysematous.  30 

infant.    2"/ 

funnel  breast.  30 

landmarks  of.  34 

normal,  description    of,   47 

pigeon    breast,   29 

paralytic,  31,    116 

phthisical,   31 

rhachitic,    29 

regions  of,  32 

transverse  constriction   of,  29 

types   of,  29 
Chautard's  acetone  test,  324 
Chill,   1.32 
Chlorosis.   60 
Cholelithiasis.   67 
Cholera,  stools  of.  341 
Cholesterin  in  pneumonia.   135 
Choroiditis.  88 
Clavicle,  relation  to  ribs.  41 
Clubbing  of  fingers,  toes.  104.  112.  157, 
223 

causes  of,  105 
Coin  ring,  86.  128 
Colic,  abdominal.  274 

hepatic,  276 

intestinal,  279 

renal,   276,   279 
Colitis,   membranous,  i";}, 
Coloptosis,  280 
Concretions,  bronchial,    146 

pulmonic,  146 
Congenital  heart  diseases.  222 
Constipation,   84.    270.   3,';7 


Consumption,  143 

(see  Tuberculosis) 
Cor  Bovinum,   163 
Corpuscles,  red,  237 

counting,  243 

white,  238 
Corrigan  pulse,  58 
Corset  wearing,  effects  of.  260 
Cough,  91 

in  aneurysm,  230,  2,34 

in   bronchiectasis,   24 

causes  of,  91 

characteristics   of,   92,    133 

dry,   91 

moist,  91,  93 

paroxysmal,   107 

stomach,  91 

sympathetic' 92 

varieties,  91 

whooping,  92 
Cracked    pot    sound,    75,    121.    T31,    132, 

152  ■ 
Crenation,   237 
Crepitans  redux,  132 
Crepitation,  86 

gall    stone,   275 
Crepitus,   86 
Crescents,    249 
Crook's   tubes,  342 
Croupous    pneumonia,    129 
Crystals,   Charcot-Leyden.  94 

in   leukKmin,   251 
Curschmann's  spirals.  94,    1 1 1 
Cyanosis,    103,    223 

causes,  104 

chronic,    104 

congenital.     103 

relation   to  dyspnoea,    104 
Cyrtometer,  51 
Cystin,  329    ■ 
Cytomcter.  Thoma-Zeiss,  241 

D 

Daland's  hxmatocrit.  245 
Dare's  hjemoglobinometer.   i~,T, 
Deglutition  pneumonia,   i.V> 
Dexiocardia,    164 
Diabetes  mellitus,  321 
Diaceturia,    324 

significance,   324 


36L 


Diaceturia — 

test  for,  324 
Diagnosis  defined,  18 

importance  of,  22 

methods,  17,  ig 

x-ray  in,  342 
Diaphragm,  32 

anatomj-  of,  32,  42 

in  emphysema,   109 

height   of  domes,  32,  2i7 

openings  in,  42 
Diarrhoea,  338 
Diastolic   murmurs.   206 
Diazo  reaction  of  Ehrlich,  325 
Dicrotic   notch,    65 

wave,  64 
Digestion  products,  302 
Digiti    Hippocratici,    104,    112 
Dilatation,  cardiac,  223 
Diplococcus  pneumonise.  134 

examining  for,  134 
Direct  murmurs,  184 
Divisions   of  bronchi,   41 
Donne  5  test  for  pus,  319 
Doremus'  ureometer,   313 
Dropsy,    (see   Ascites) 
Dry  pericarditis,  190 
Ductus  arteriosis,  patent,  222 

in  heart  diseases,  222 
Dullness,  definition  of,  72 
Dysentery,    280 

agglutination  test   for.  281 

bacteriolog}',  280 

differential  diagnosis,  281 

stools  of,  341 

varieties,  280 
Dyspnoea,  99 

anaemic,    100 

aneurysmal,   230.  233 

of  bronchial  stenosis.  115 

causes   of,   99 

cardiac,  99,  214 

chemical,   ico 

classification,  100 

expiratory,    100 

inspirator)-,   100,  III,   130 

larj'ngeal,  99,   no 

mechanical,   100 

nervous,    loi 

of  pulmonary-  embolus,   140 

paroxysmal,    103.   115 


Dyspnoea — 

of  pneumonia,    loi,   130,   133 
physical  signs  of,  100 
renal,    103 
of    tuberculosis,    156 


Eberth's    bacillus,    340 
Echo,  amphoric,  87 
Echinococcus,  285 
Effusion,  pleuritic,  117 

point  for   tapping,   34 
Egophony,  85,   119,    131 
Ehrlich's    diazo   reaction,    157, '  325 

triacid   stain,   247 
Eichhorst's  pulse  scale,  55 

corpuscles,   250 
Elastic  tissue,  test  for,    154 
Ellis'  curve,  118 

Embolism  of  pulmonary  artery,    139. 
-    diagnosis  of,  140 

physical  signs  of,  140 
Embryocardia,   225 
Emphysema.   108 

compensatory,   108 

diagnosis  of,  109 

physical  signs  of,   108 

varieties,   108 
Emphysematous  chest,  30,  108 

causes  of,   30 
Endocarditis,   acute,    226 

rnalignant,  causes  of,  226 

symptoms  of,  227 

simple,   causes   of,   226 

symptoms,  226 
Endocardial    murmurs,    176 
Ensiform   cartilage,  41 

variations  in,  41.  260 
Enteroliths,   341 
Enteroptosis.  280 
Eosinophiles,  238 

in  leukaemia.  251 
Epigastric  pulsation.   163.  206 

significance  of.   163 

region,  41 
Epileptics,  pulse  rate  of,  57 
Erj'throcj'tes,  236 
Ethereal   sulphates,  315 
Ewald's  test  meal,  297 

salol  test,  305 
Fwarf s  sign,  193 


362 


Exocardial    nuirnuu-s.    77 

Expectoration,  93 
anionnt,  93 
of  broncliitis,  107 
of   pneumonia,   133 
of  phthiiis,   154 
varieties,  93 
(see  also  Sputum) 


Faeces,  337 

acholic,  340 

blood   in,   274,   338 

in    cholera,    340 

in  colitis,  273 

composition,  337 

consistency,  338 

in  diarrhoea,  340 

in  dysentery,  341 

gall  stones  in,  341 

gases  of,  340 

inspection,  337 

in  intestinal  catarrh.  273 

odoi-,  338 

palpation  for  accumulations.  28c 

reaction,   339 

quantity.   339 

in  typhoid,  340 
Faecal    accumulations,    280 

signs  of,   280 
False  murmurs,  187 
Fehling's  glucose  test,  322 
Fever  in  broncho-pneumonia.   137 

in  haemoptysis,  96 

hectic,   153 

in   phthisis,    153 

in  pneumonia,  132 

in  pulmonary  abscess,  132 

pulse  rise  in.   56 
Fixation  of  blood  films,  246 
Flatness  defined,  72,  75 
Fleischers  gastric  motor  test,  304 
Flint's  murmur,  212 

vesiculo-tympanx-,  119 
Fluctuation,  262 

circumscribed,  262 
Fluoroscope,  342 
Foetal  heart  sounds.  291 
Fossa,  34 

infraspinous.  34 

supraclavicular.  33 


Fossa — 

supraspinous,  34 
Friction  sounds,  83,  177.  190.   194,  262 

diagnosis  of,  84 
Friedreich's   sig^n,  195 
Fremitus,  52 

abdominal,  262,  264 

cardiac,  166 

diminished,  53 

factors  of,  52 

friction,  54,   130 

normal,  54 

pericardial,   190 

pleural,   116 

in  pneumonia,   53.    130 

rhonchial,  54,  no,  112,  152 

tactile,  52 

tussile,   54 

variations,  53 

vocal,  84 
Funnel   breast.   30 

causes,  30 

Q 
Gall  bladder,  41,  275 

enlargements  of,  42 

palpation  of,  42,  275 
Gall  stone  disease.  275,  341 

differential    diagnosis,    276 
Galloping  consumption,  143 

rhythm,  191,  208 
Gangrene,    intestinal.    281 

pulmonary,    132 
GaStrectasia.  269 
Gastric  carcinoma,  250,  269 

lactic  acid  in,  305 
Gastric  contents,  examination  of.  296 

absorption,   304 

test  for,  304 

acetic  acid  in,  298.  300 

acid  salts  of,  302 

Boas'  test  for,  299 

Boas-Oppler  bacillus   in.  305 

butyric    acid    in,   298,    300 
smell  of,  300 

test  for,  300 

chemical  examination  of.  300 

digestion   products.    302 

free   acid,  296 

free  HCl,  296 

estimation  of.  301 

juice,   296 


363 


'Gastric   contents — 

lactic  acid  in,  297 

after  test  breakfast,  298 
test  for,  300 

microscopic  examination,   305 

motor    function,    304 

mucus,  305 

organic  acids,  299 
test  for,  300 

pepsin,    303 

reaction,   29S 

rennin,  304 

sarcinse,   305 

total    acidity,    300 
■Gastroxynsis,  297 
Gigantoblasts,   Ehrlich's,  250 
Glucose,  320 

Fehling's  test  for,  322 

Haine's   test  for,  322 

Phenylhydrazin   test,    322 

Robert's  test  for,  323 

Trommer's  test  for,  321 
precautions,    321 
Gmelin's  test,  bile  pigment,   324 
Gollash's  dye,  248 
Gonococcus,  336 
Gower's    fluid,    244 

hffimoglobinometer,  252 
Glycosuria,   320 

qualitative  test  for,  322 

quantitative  test,  321 

significance,  320 

(see  also  Glucose) 

H 

Ha;matemesis,   60,  272 
Hematocrit,    Daland's,   245 
Hjematuria,  332 
Haemic  murmurs,  177 
Haemocytometer,  241 

Turck's  rulings,  244 
Hsemoglobin,  249 

in  chlorosis,  249 

estimation  of,  252 

in  gastric  carcinoma,  250 

in  leukaemia,  251 

in  pernicious   anaemia,   250 

in   septic  infections,   250 
-HEemoglobinometer,  Dare's,  253 

Gower's,   252 

Tallquist's,    252 


Haeraopericardium,  198 
Haemoptysis,  95 

in  bronchiectasis,   114 
causes,    95 
character  of,  96 
diagnosis,  97 

from   haematemesis,  97,  98 
in  embolus,    140 
in  emphysema,  no 
in  gastric  carcinoma,  270 
in  mitral  diseases,   199 
in   phthisis,    155 
recurrent,  96,  97 
symptoms,    96 
vicarious,  96 
Hjemorrhage,   intestinal.  98 

retinal,  89 
Haine's  glucose  test,  322 
Harrison's  sulcus,  29 
Hazer's   coefficient,   312 
Heart,    diseases    of — 

absolute  dullness  of,  37,  169 
anatomy  of,  159 
apex  impact,  160 
areas,   162,  167,  168 
dilatation,  199,  223 

physical  signs  of,  225 
displacements  of,   164 

causes  of,   164 
in  emphysema,   109 
fatty,  225 
fibroid,  226 
hypertrophy,  223 

causes,  224  , 

pseudo,   163 
murmurs,    177 

causes   of,    177 

location   of,   180 

time   of,   179 
percussion  areas,    166 

decreased,   169 

displaced,   169 

increased,   169 
physical  examination  of,   161 
physiology,   159 
rate,  159 

reduplication,   176 
sounds,  170 

altered,    174 

adventitious,    176 

elements   of,   171 


364 


Heart- 
normal,   170 
over  cavities.   152 
reduplication  of.   1O6.   176,  207 

(see  also  Cardiac) 
Heaving,  aneurysmal,  229 
Hectic,  153 

Hellers  albumin  test,  318 
Hepatization  of  lung,   129,   131 
Herpes   in  pneumonia,    132 
Hiatus  diaphragmaticus,  46 
Histologic  sediment   of   urine,   330 
Historj'  taking,  21 
Hippocratic  succussion,  86,   128 

in  pneumothorax,  128 
Hodgkin's   disease,  254 
Hydrochloric  acid,  296 

in  gastric  contents,  298 

qualitative   test   for,   299 

quantitative  test  for.  301 

significance,  302 

tests   for,  299 
llydropcricardivnn,  197 
llydropneumothorax,    125 
Kypcrchlorhydria,  297 
Mypcrlcucocytosis,  240 
llyperresonance,  74 
Hypertrophy,    cardiac.    223 

causes,  224 
Hypobromite  solution,  313 
Hypoleucytosis,  240 
Hyperostosis  of  Marie,   112 


Infrninamniary — 
right,  38 
Infrascapular  region,  34 

contents,  45 
Infraspinous   fossa,  34 
Inorganic  murmurs,  177 
Inspection,  47 

rules  for,  47 

in    intestinal   diseases,   271 
Insufficiency,  aortic,    183,    186 

mitral,   198 

pulmonary,   220 

tricuspid,  217,  219 
Intermittent  venous  murmurs,  63 
Interscapular    region,    34,   45 

boundaries,   45 

contents,  45 
Intestine,  .270 

catarrh   of,   272 

glands   of,   270 

large,  anatomy  of,  279 
diseases  of,  270 

obstruction   of,  273 

perforation,   signs    of,   278 

small,  270 

anatomy   of,   270 
diseases  of,  270 

special  symptoms,  270 

ulcer  of.  276 
Intussusception,  274 
Iodoform  test.  Fleischer's.  304 
lodophilia,  239 


I 

Ileus.  273 

Incisnra  of  lung,  45 
Indirect  murmurs,  184 
Indol,  315 

in   intestinal  obstruction,  315 

in  peritonitis,  315 
Indican  in  urine,  274 

significance  of,  315 

test  for,  26s,  315 
Inferior  axillary  region,  34 

contents,  45 
Infraclavicular   space.   33,  36 

boundaries,  33 

contents,  36 
Inframammary  region,  33 

boundaries,  33 

contents,  left.  ^iJ 


Jenner's  stain.  24S 

K 

Kidneys.  45.  289 

anatomy,  45,  289 

enlargements  of,  289 

movable,  290 

palpation,  289 

percussion  areas,  289 

physical  examination  of,  289 

tumors  of,  290 
Klemperer's  gastro-motor  test,  304 
Koch's   coma    bacillus.    340 


Lactic  acid,   .^oo 

in    gastric    contents,   300 
Ufflemann's    test    for.    300 


365 


Lasnnec's   purring    tremor,    i66 

perles,  94 
Landmarks  of  thorax,  SS-  34 

of   ribs,    34 
Laryngoscope,   87 

diagnosis  by,  88 
Larynx,  ulcer  of,  88 

hjemorrhage  from,  98 
Laryngeal  breath  sounds,  loi 

stenosis,  99 

dyspnoea,  99 
Laryngismus  stridulus,    104 
Lavaran's  Plasmodium,   248 
Leadworker's  pulse,  57,  67 
Leo's   test   for   acidity,   302 
Leucocytes,  236 

basophilic,    239 

classification,  239 

counting,  244 

eosinophilic,    239 

large  mononuclear,  239 

neutrophiles,  239 

normal    number,    239 

polynuclear,  239 

in  pernicious   aujemia,   250 

in  pulmonary   tuberculosis,   254 

reaction  to  iodine,  239 

small  mononuclear,  239 
Leucocytosis,   237,  240 

absence  of,  240 

basophilic,  240 

causes  of,  240 

eosinophilic,  240 

experimental,  240 

inflammatory,  240 

in  malignant  disease,  240 

pathologic,   240 

pneumonic,  135 

post  hjemorrhagic,  240 

physiologic,  240 

therapeutic,  240 

toxic,  240 
Leucin  in  urine,  329 
Leukemia,  251 

diagnosis  of,  252 

lymphatic,   251 

splenomedullary,  251 
Line — 

mammary,  33 

midaxillary,   34 

midclavicular,  33 


Line — ■ 

midscapular,  34 

parasternal,   33 
Lithogenous  biliary  catarrh,  275 
Litten's,  phenomenon,  147,  195 
Liver,   282 

abscess,  281 

symptoms  of,  283 

acute  yellow  atrophy,  285 

alterations  of  position,  283 

anatomy  of,  37,  76 

amyloid,  284 

borders  of,  38,  76,  282 
in  atrophy,  285 

cancer    of.    284 

changes  in  size,  283 
in   amyloid,   284 

cirrhosis,  atrophic,  285 

hypertrophic,   284,  294,  318 

cysts  of,  293 

displacements,   283,   286 

enlargements,  275 

echinococcus,   285 

fatty   infiltration,  284 

hyperemia  of,  283 

lymphadenomata,  285 

normal  boundaries,  38,  76,  282 

nodules,  284 

pulsation,  62,  164,  199,  218,  283 

syphilis  of,  285 
Lobar  pneumonia,  129 

bacteriologj',    134 

blood  changes  in,  135 

diagnosis,    135 

special  symptoms,  132 

terminations,  132 
Lungs — 

abscess  of,  95,  132 

altered  sounds,  78 

anatomy  of,  45 

apex  areas,  35 

auscultation,    76 

blood  from,  96 

borders  of,  45,  7S 

cirrhosis,  294 

collapse  of,   114 

conditions   causing  cough,   91 
causing  clubbing,   105 

consolidation,   149 

expansion,  types  of,  48 

in  embolism,  139 


3(i6 


INDEX 


Lungs- 
gangrene  of,  132 
hepatization  of.  131.  140.  143 
inspection,  47 
lobes  of,  39 
outlines  of,  75 
a;denia   ctf.    135.    141 

diagnosis,    135 
palpation,  52 
percussion.  70 
percussion  note.  71 

changes  in,  73 
in  pericarditis,  193 
in  pleurisy,    121 

compression  of,    121 
in   pneumothorax,    125 
relation  to  clavicle.  35,  75 

to  pleura,  45 

to  sternum.  38 

to  thorax,  75 
retractions,  151 
symptoms  pointing  to.  20 
Ludwig's   angina,    100 
L\Tnphocytes.  238 

in  Hodgkin's  disease,  254 
in  leukaemia,  252 

M 

McBurney's  point,  277 
Alacroblasts.  236 
Macrocytes,  236 
Malarial  organism,  248 
Mast  cells,  238,  252 

in  leukaemia,  252 
Mammary  region,  31 

boundary.  31 

contents,   37 

line.  31 
Mechanical  aids  to  diagnosis,  63, 
Mechanical   dyspnoea,  100 
Meconium.  340 
Mediastinal   growths,  99,   235 

diagnosis  from  aneurysm.  169, 
from  cardiac  hypertrophy, 
Megaloblasts.   237 
Medical  anatomy,  32 
Megalocytes,  236 

in  pernicious  anaemia.  250 
Meningeal    disease,    influence    on 

57 
^lensuration,  51 


Metallic  tinkle,  86,  127.   153 

in  intestinal  obstruction,  274 
Microblasts,  22,7 
Microcytes,  236,  250 
Microscope — 

findings  in  faeces,  341 
in  stomach,  305 
in  urine,  330 
Midaxillary  line,  34 
Midclavicular  line.  2,:^ 
Midscapular  line.  34 
Mitral  area,  i8i 

incompetency,    198 
diagnosis  of,  203 
mechanism  of,   198 
physical  signs  of.  198 
incompetency  and  stenosis,  209 

physical   signs  of,  209 
murmurs,  183 
stenosis,  184,  204 

physical    signs  of,   205 
mechanism  of,  204 
pulse  of,  208 
thrill,   200 
valve.   160 
Morbus  coeruleus,  104 
Movable  kidney,  290 
Mucus,  gastric,   305 

urinary.  319 
Murmurs.    177 

anasmic.  177,   216 
aortic.    185 

incompetency,  20Q 
stenosis,  186,  214 
arterial,  62 
areas  of,  181 
associated,  179.  212 
auricular  systolic,   179 
87.  88        cardiac,    177 

cardo-respiratory,  148 
causes  of,  177 
combined,  179 
235  congenital,  222 

169  compound.   179 

de  diable.  179 
diastolic,  lok 
direct,   184 
endocardial.   176 
pulse.         exocardial.    177 
false.  63.  187 

causes  of.  187 


367 


Murmurs — 

diagnosis  of,  189 

Flint,   212 

hsemic,   177 

indirect,  184 

location  of,   180 

mitral,   183,  200 

obstructive,  204 

order  of  frequency  of,  178 

organic,   178 

presystolic,  184,  202 

of  phthisis,    148 

pulmonary,    220 

simple,    179 

steam- tug,  217 

systolic,  200 

time   of,    179 

tricuspid,  202,  217,  219 

uterine,  63 

venous,  61 

ventriculo-diastolic,   180 
systolic,  180 
Myocarditis,  226 
Myocardium,  diseases  of,  223 
Myoidema,   151 

as  sign  of  phthisis,  151 
Myelocytes,  251 

N 
Negative  pulse,  61 

wave,    66 
Nervous  dyspnoea,  102 
Nephritis,  90 

scarlatinal,  100 
Night  sweats,  156 
Nipple,   34 

line,  33 

landmark,   35 

location  of,  34 
Neutrophiles,  238 

polymorphonuclear,  238 
Neutrophilic,   238 
Normoblasts,  237 
Normocytes,  238 
Notch— 

dicrotic,  65 

interclavicular,  35 
contents   of,  35 

suprasternal,  33 
Nucleated  red  cells,  237 

in  pernicious   anaemia,  250 

in  leukaemia,  251 


O 

Obstipation,  337 

Obstruction  of  bile  ducts,  275,  283 

of   gall  bladder,  275 

intestines,  273 
CEdema — 

of  abdominal  walls,  264 

of  aneurysm,  231 

diagnosis  of,  142 

of  heart  disease,   142 

pulmonary,    141 

terminal,  141 
.  CEsophagus,  229 
Oligocythemia,   237 
Oliver's  sign  of  aneurysm,  232 
Omentum,  293 

cancer  of,  293 

diagnosis  of,  294 

diseases  of,  293 

tumors   of,  293 
Ophthalmoscope,  88 

diagnosis  by,  89 
Openings   in  diaphragm,  42 
Order  of  procedure  in  diagnosis,   32 
Orthopnoea,  103,  233 
Osteo-arthropathie  pneumique,    112 
Ovaries,  palpation  of,  292 

diseases  of,  292 
Ovarian  dropsy,  293 

diagnosis  from  ascites,  293 

tumors,   292 

diagnosis  of,  293 
Oxalate  of  lime,  328 
Oxyphilic,    238 


Palpable  rales,    (see  Rhonchi) 
Palpation,    52 

abdominal,  261,  271,  280 

of  aorta,  35 

of  appendix,  271 

differential,    147 

for  fluctuation,  262 

for  fjecal  accumulations,  280 

friction  fremitus,  54,  130 

of  gall  bladder,  42,  27s 

in  intestinal  diseases,  261 

of  kidney,  289 

of   liver,  37 

of  lung,   52 

of  omentum,  293 

of  ribs,  34 


308 


Palpation — 
spleen,  286 
ulnar,  52 
stomach,  266 
thrill.  166,  200,  206 
Palpation  in  disease,  52 
aneurysm,  229 
bronchitis,  106 
bronchial  stenosis,   115 
broncho-pneumonia.   138 
emphysema,    109 
lobar  pneumonia,   130 
peritonitis,  264 
phthisis,    147 
pericarditis,   192,   196 
Papillitis,  89 

Paracentesis  of  pleural   sac.  45 
Paralysis,  laryngeal,  88 
Paralytic  chest,  31 
Parasternal  line,  33 
Patent  ductus  arteriosus,   222 
Pectoriloquy,  85,  153 

in   bronchiectasis,    1 13 
cavernous,  85 
in  phthisis,  152 
Pigeon  breast,  29 
Peptones,  test   for,  303 
Pepsin,  303 

test  for.  303 
Percussion,  70 

of  abdomen,  262 

abdominal  organs,  262 

for  abdominal  fluids,  295 

auscultatory,   26 

for   f;ecal  accumulations.  280 

of  heart.  166,   167 

immediate,  70 

intensity  of  sounds,  73 

intestinal   tumors,  263.   271 

law  of  duration,  73 

of  liver,  284 

of  lung,  73.  75 

mediate,  70 

prsecordia,   161,  169 

rules  for,  70 

scale,  73 

sounds,  influences  modifying.  74 

theory  of,  73 
splenic  area,  287 
stomach   area,  266 


Pericardial  effusimis.    105 

diagnosis  from   dilatatinn.   194 

signs  of,   192 
Pericardial   murmurs.    17(1 
Pericarditis,  190 

adhesive,  195 

diagnosis  fnnn  pleurisy.   124 

physical  signs  of.   195 

causes  of,   190 

dry,  190 

diagnosis  of.    190 
physical    signs   of.    191 

leucocytosis  in,  241 

percussion  areas  of,   169 
Peristalsis,  270 

gastric,  304 

visible,  280 

significance  of,  271 
Peritoneum,   264 
Peritonitis,   264 

in  appendicitis,  27b 

physical  signs  of,  265 

varieties,  264 
Pernicious  anaemia,  250 
Perles  of  Lsennec,  94 
Perspiration  of  phthisis,  156 
Phonendoscope,  26 
Phthisical  cavities,  151 

chest,  31 
Phthisis,  143 

(see  also  Tuberculosis) 

acute  pneumonic,  143 

auxiliary   signs  of,   153 

chronic,   144 

incipient  stage  of,  146 
stage  of  consolidation,  149 
softening,  151 

classification   of.    143 
florida,  143 

physical  signs   of,   143 
Phenylhydrazin   test  for   glucose.   322 
Phosphates    in   urine,   316.   327 
Phosphoric   acid,    significance    of.   316 

tests  for,  316 
Physical  examination,  order  of.  32 
Pitch,  law  of,  73 

in  pneumothorax,  126 
Placental   bruit,  291 
Plasmodium  malaris.  248 
Plessor,  70 


369 


Pleura,    relation   to   lung,  45 
Pleural    fremitus,    116 

effusion,  tapping,  45 
Pleurisy,  116 

compressed  lung  in,  121 

diagnosis  of,  123 

from  pericarditis,   124 

dry,    116 

with  effusion,   119 

physical  signs  of,  117 

varieties  associated   with  pu 
tuberculosis,   146 
Pleuritis  sicca,  116 
Pleurodynia,    123 
Plexiraeter,  71 
Pneumonia,  129 

catarrhal,  136 

chronic,  137 

croupous,  129 

diagnosis  of,  135 

embolic,   139 

lobar,   129 

special   symptoms   of,   132 

sputum  of,    133 

stages,   129 
Pneumopericardium,    198 
Pneumothorax,  125 

causes  of,  125 

physical  signs  of,  126 
Poikilocytes,  236,  237 

in  Hodgkin's  disease,  254 

in  pernicious  anfemia,  250 

in  splenic  anaema,  254 
Polycythsemia,    237 
Polyuria,  321 
Post-tussive  suction,  87 
Potassium  ferrocyanide  test  for 

min,  318 
Praecordia,  161 
Predicrotic  wave,  64 
Presystolic  murmurs,  184 

thrill,   206.   219 
Pressure  symptoms  of  aneurysm 

murmurs,  62 
Proteolysis,  302 
Puff,  87 
Pulmonary — ■ 

atelectasis,  114 

apoplexy,   139 

artery,  obstruction  of,  139 

compression,  127 


Pulmonary — ■ 

embolism,  99,  139 

diagnosis  of,    140 
dyspnoea  of,   140 

oedema,    141 

percussion  note,   71,  73 

stenosis,   220 

valve   murmurs,    186 
areas,    182 

thrill,  220 
Imonary        tuberculosis,    143 

(see  also  Phthisis  and  Lung) 
Pulsation,    epigastric,    163,    206 

venous,   59,    165,    199,   218 
Pulse,  55 

of  aneurysm,   234 

of  aortic  insufficiency,  63 

arhythmia,   58 

asymmetry,  58,  231 

bigeminus,  59,  68 

capillary,  63 

cycles,  56 

dicrotic,   59,   67 

Eichhorst's  scale,  55 

in  epilepsy,  57 

factors  of,  55 

frequency,  55 

diminished,  57 
increased,  56 

high   tension,   66 

lagging,  56 

negative,  61 

paradoxus,  197 

quality,  57 

respiration  ratio,    100 
in  pneumonia,  133 
albu-  rhythm,  58 

temperature  ratio,   56 
in  phthisis,  56 

thrill,  59 
Pulsations,  cervical,  164 

epigastric,   163 
230  retinal,  89 

Pupil   in   aneurysm,   234 
Puerile  breathing,  78 
Purpura,  254 
Pus- 
characteristics  of,  331 

casts,   335 

in  urine,  330 

in  stools,  341 


370 


Pus- 
tests  for,  331 

Pylephlebitis,  60 

Pylorus,  266 

location  of,  266 
obstruction  of.  268 
stenosis.  269 
tumors  of,  269 

Pyopneumothorax.  125 


Rachitic  chest,  29 
causes  of,  29 
rosary,  29 
Radial  pulse  retardation,  63 
Radiography,  343 

in  aneurysm,  230 
Radioscopy,   343 
Rales,  8i 

crepitant,  81,  130 

significance  of,  82 
crackling,  82 
definition  of.  82 
dry,  82 

gurgling,    82  I 

mucous,  82 
moist,  82 
'  classification  of,  82 

redux,   131 
sibilant,  83 
sonorous,  83 
subcrepitant.    107 
Red  blood  corpuscles.  237 
crenation  of,  237 
enumeration  of.  243 

by  haeniatocrit.  245 
granular  degeneration  of.  237 
nucleated.  237 
in  pernicious   anaemia.  250 
variations   in   number,   237 
shape.    237 
size,  237 
Reduplication  of  heart  sounds.   166, 
225 

significance.   166 
Regions  of  chest.  31 
axillary,   33 
superior,  43 
inferior,  42 
clavicular.  35 
epigastric.  41 


Regions  of  chest — 
infraclavicular,  36 
inframammary,  ^S 
left,  3,8 
right,  37 
infrascapular,  34 
interscapular.   34,   45 
mannnary.   .33.   37 
scapular.  34.   45 
sternal,  35 
supraclavicular,   35 
suprasternal,  35 
Regurgitation.   185 
aortic.   183,    186 
mitral,  185 
pulmonary,    186 
tricuspid,  202 
Renal  asthma,  no 

cysts,   293 
Resonance,    amphoric,  75 
cavernous,  80 
diminished.    74 
impaired,  74 
increased,   74 
normal  percussion.  71 
Skoda"s,    74.    119.    193 
tympanitic,  71,  74 
vesiculo-tympanitic,  71,  193 
Respiration — pulse  rate,  100,   133,  136 
Respirations — 
cog-wheel,  79 
normal   number,    100 
rude,  78 
types   of,  48 
Respiratory  sounds,  77 
interrupted.    79 
in   phthisis.    148 
in  pneumonia.   129 
suppression   of.   79 
tremor.  83 
Retinitis.  90 
Rhonchi,  82 
176.         sibilant.  83 
sonorous,  83 
Ribs,  counting,  34 
landmarks  of,  34 
palpation  of,  34 
Right  ventricular  hypertrophy,   169 
Romanowsky's   stain,  249 
method  of  using,  249 
Rosary,  rickety.  29 


371 


Rotch's  sign,  124,   193 
Roentgen  ray  in  diagnosis.  343 
apparatus,  343 
examination  b\',  344 
of  abdomen,    350 
of  thorax,   341. 
technique  of,  344 


Salol  test  of  Ewald,  305 
Sarcoma,    interabdominal,  272 
Scapula,  location  of,  34 
Scapular  region,  34 

contents,   45 

division,  45 

situation,   34 
Scrobiculis  cordis,  41 
Semilunar  space  of  Traube, 
Sign— 

Ewart's,   193 

Friedreich's,  60,    195 

Litten's,  147,  195 

Oliver's,  232 

Rotch's,   124,   193 

Smith's  of  aneurysm,  232 

Traube's  vascular,  63 
Signs,    physical,    20 

subjective,  19 
Skiagraph,  343 
Skoda's  resonance,  74 

identity  with  Flint's,  74 

in  pericarditis,  193 

in  pleuritic  effusion,  74 

vesiculo-tympany,   74 
Sleep,  influence  on  pulse,  58 
Small  intestine,  diseases  of,  270 

anatomy  of,  270 
Smith's  sign  of  aneurysm.  232 
Sound.s — 

adventitious.  Si 

endocardial,   76 

foetal  heart,  291 

pericardial.    176 
Souffle,  funic,  291 
Spermatozoa  in  urine,  336 
Sphygmograph,  63 
Sphygmometer,  68 

Stanton's,  69 
Spirals   of  Curschmann,   94 
Spleen,  45,  286 

cysts  of:  293 


Spleen — 

enlargements  of,  125,  288 
diseases  causing,  288 

fremitus,  264 

percussion  areas,  286 

topography,   45,  46,  286 
Splenic  anjemia,  237 

area,   287 

ascites,  294 

axis,  45,  287 

line,  287 
Sputum,   (see  Expectoration),  93 

in  acute  bronchitis,   107 

amount,  93,   133 

in  bronchial  asthma,  94 

in  bronchiectasis,   113 

consistency.  93 

color,  93 

in  lobar  pneumonia,   133 

nummular,  93.  154 

in   pulmonary  abscess,   132 

in  pulmonary  oedema,  93,   142 

in  pulmonary  tuberculosis,  93 

rusty,  29,  133,  138 
Squibb's  urinometer,  77 
Stenosis,  aortic.  214 

bronchial,   1 14 

intestinal,   272 

mitral,  204 

pulmonary,  220 

pyloric.  269 

tricuspid,  185.  219 

valvular.   178 
Sternal    region,   33 

boundaries,  33 

contents,  38 

division   of.   33 
Slethometer.  51 
Stethoscope.  23 

Bowles",  description  of,  25 

necessary  qualities,  24 

Valentine's,   24 
Stomach.  265,  296 

(see  Gastric) 

alterations   in   size.   267 

artificial   distention,  267 

carcinoma  of,  250,  269 

cardiac  orifice,  46,  266 

contents,  examination  of,  :g6 

lavage,  29S 

locating  lower  border,  267 


■ST. 


Stomach — 

motor  function,  304 
testing,  30s 

physical  examination  of,  266 

pyloric  orifice,  266 

rate  of  absorption,  304 

topography,  266 

as  determined  by  x-ray,  350 
Stridor,  83,  115 

of  Taylor  and  Lee,  104 
Snbscapular  region,  34 

boundaries,  34 

contents,  45 
Succussion  splash,  86,   128 
Suction,  post-tussive,  87 
Sugar  in   urine,  320 

(see   Glycosuria^ 
Sulphuric  acid  in  urine,  315 
Sulphates,  315 

significance  of,  315 

tests  for,  315 
Supraclavicular  fossa,  33 

contents,  35 
Supraspinous  fossa,  34 
Superior  axillary   region.   33 

contents,   42 
Suprasternal  region,  33 

contents,  35 
Sweating  unilateral,  234 
Symptoms,  20,  91 

classification  of,  21 
Syphilis,   hepatic,   285 

laryngeal.  88,  98 
Systolic  murmurs,   217 

rhythm  of,  179 


Tachycardia,  104 

Tactile   fremitus,  52 

factors  diminishing.  50 
increasing,  52 

Tallquist's  haemoglobinometer.  252 

Tapping  pleural  sac,  45 

Test  meal,  297 

Thoma-Zeiss  cytometer,    241 

Thoracic  aneurysm,  228 
(see  Aneurysm) 
physical  signs  of,  233 
pressure  symptoms,  230 

Tenesmus,  270 
in  dysentery,  281 


Temperature — pulse  ratio,  56 
Thorax,  27 

(see  Chest) 
emphysematous,  30 
infantile,  27 
paralytic,  31 
phthisical,  31 
shapes  and  types,  27 
Thrill,  aortic,  215 
aneurysmal,  230 
arterial,  59 
hydatid,  285 
Laennec's,   iWi 
mitral,  200 
pericardial,    166 
pulmonary,  2J0 
presystolic,  20().   219 
purring,    166,   206 
tricuspid,  2ig 
Thrombosis,  60 
Tinkle,  metallic,  86,  127 
Toison's  fluid,  244 

Tonsillar   hypertrophy,    influence  on   re- 
spiration, 29,  30 
Topfer's  test  for  HCl,  299 
Tormina,  270 

Trachea,  bifurcation  of,  38 
Tracheal  tug,   232 
Traube's  vascular  sign,  63 

semilunar  space. 
Triangle  of  cardiac  dullness,  37.   167 
Trichter  brust,  30 
Tricuspid  area,  182 
murmur,  185 
regurgitation,  185,  217 
causes  of,  217 
diagnosis  of,  219 
mechanism  of,  218 
physical  signs  of,  218 
stenosis,  185,  219 

physical  signs  of,  219 
thrill,   219 
Trommer's  test  for  glucose,  321 
Tubercle  bacillus,   155 
of  choroid,  88 
in   phthisis,    155 
staining.   155 
in  urine,  336 
Tuberculosis,   pulmonary,    143 
(see  also  Phthisis) 
Auscultation,   147,   151,   152 


INDEX 


375 


Tuberculosis — 

auxiliary  signs  of,  153 

blood  in,  157 

classification,  143 

cough  in,   144,  153 

DaCosta's  sign  of,   148 

definition,  143 

earliest  signs  of,  148 

expectoration  of,   154 

intestinal,  272 

laryngeal,  88 

lesions  of,  145 

methods  of  examining,  146 

myoidema  as  sign  of,  157 

palpation  in,   147,  150 

percussion  in,   147,   150 

physical  signs  of,  146,  153 

pleurisy  associated  with,  146 

primary  lesions  of,  144 
seat  of,  144 

rectal,  338 

sputum  of,  155 

stages,  146 

varieties,   143 
Twin  pregnancy,  diagnosis  of,  291 
Tympanites,    270 
Tympany,  263 
Typhoid  fever,  Widal's  test  for,  281 

diazo  reaction  in,  325 
Tyrosin  in  urine,  330 

U 

Uffelmann's  test  for  lactic  acid,  300 
Ulcer  of  duodenum,  272 
Ultzmann's  test  for  chlorides,  316 
Ulnar  palpation,  52 
Uraemia,    100,  308 
Ureometer,  Doremus',  313 
Urinary  sediment,  325 
Urine,  307 

acetone   in,  310 

acid   sediment,   326 

albumin,  317 

tests  for,  318,  319 

alkaline  sediment,  326 

ammoniacal  decomposition,  309, 

appearance,  318 

in  appendicitis,  278 

bacteria  in.  336 

bile  in.  276,  324 

bile  pigment  in,  278.  324 


Urine — 

blood  in,  331 

tests  for,  332 
calcium  oxalate  in,  328 
carbohydrates  in,  320 
casts  in,  333 

bacterial,  336 

blood,  332,  334 

epithelial,  335 

fatty,  33S 

granular,  335 

hyaline,  334 

P"s,   335 
changes  on  standing,  309 
chlorides,  315 

significance  of,  315 

test  for,  316 
composition,  308 
color,  310 
cylindroids   in,   336 
cystine  in.  329 
diacetic  acid  in,  324 
epithelium,  332 
glucose,  320 
in   hepatic   colic,   276 
hippuric  acid,  328 
indican,  265,  274 

tests  for,  265 
in  intestinal  obstruction,  274 

catarrh,  273 
leucin  in,  329 
mucin  in,  319 
nubecula.  309 
odor,  310 

oxalate  of  lime  in,  328 
in  peritonitis,  265 
phosphates  in.  316,  327,  328 
in  pleurisy,  125 
in  pneumonia,  130,  135 
in  pulmonary  tuberculosis,  157 
pus   in,  317,  319,  330 
quantitv',  normal.  307 

variations  in.  307 
reaction,  310 
salic\lic  acid  in,  305 
336        solids  of,  312 

significance  of 

diminution,  312 
specific  gravitv-,  311 
spermatozoa  in,  336 
sugar  in.  320 


374 


Urine — 

sulphuric  acid  in,  315 

sulphates  in,  315 

transparency,   312 

in  typhoid.  247 

tyrosin   in,   330 

in  tuberculosis,  157 

urates  in.  327 

urea  in,  313 

Bartley's  method.  314 

uric  acid  in.  315 

uric  acid  calculi.  327 
Urinonieter,  31 1 
Uterus,  290 

enlargements  of.  291 

impregnated,  291 

physical  examination  of,  293 

tumors   of.  292 

V 

Valentine's   stethoscope.-  24 
Valves,  cardiac,  160 
areas,  174 
aortic,  insufficiency  of.  183.  186 

stenosis  of,  186.  214 
cardinal   points   for.   174 
congenital  diseases  of,  222 
differentiation  of  sounds.  174 
insufficiency.  17S 
isolation  of,  173 
location   of,   173 
mitral,  insufficiency  of,  19S 

stenosis   of,    184,   204 
names  of,  160 
pulmonary,  insufficiency  of,  220 

stenosis  of.  220 
tricuspid,  insufficiency,   185,  217 
stenosis,  178 
Valvular  lesions  of  tuberculosis,  151 


Vascular  phenomena,  59 

of  aortic  insufficiency,  63 

venous,  59 
Veins,  enlargement  of,  59,  165 

conditions  causing,  59 

significance  of,  59,   165 
Venous  engorgement,  60,  192 

murmurs,  61 

pulsations,  59,  165.  ton.  218 
in  phthisis.  61 
time  of,  61 

transmitted,  diagnosis  of,  60 
as  sign   of   tricuspid   regurgita- 
tion, 61 
Ventricles,  thickness  of.  223 
Vesicular  breathing.  78 

percussion  note,  71 
Vesiculo-tympany,    71.    109 
Vocal  resonance,  altered.  84 

normal,  84 
Voice,  amphoric,  85 

auscultation.  84 

cavernous,    153 

in  pneumothora.x.  127 

in  phthisis.  153 

whispered.  85 
Volvulus.   274 
Vomit,  stercoraceous.  274 

W 

Water  hammer  pulse,  58 
Whisper  resonance.  86 
Whooping  cough.  92 
dyspncea  of,  99 
Wintrich's  changed  note.  152 


Xiphoid  cartilage.  41 


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